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THE PELVIC INLET.
(From a Pliotograph.J
How TO Use the Forceps.
WITH AN
INTRODUCTORY ACCOUNT
OF THE
FEMALE PELVIS
AND or THE
Mechanism of Delivery.
y
BY
HENRY G. LANDIS, A.M., M.D.,
PROFESSOR OP OBSTETRICS AND DISEASES OP WOMEN AND CHILDREN
IN STARLING MEDICAL COLLEGE.
ILL USTRA TED.
NEW YORK :
E. B. TREAT, PUBLISHER, 5 COOPER UNION.
For Sale by Medical Booksellers.
1889.
[copyright, 1880.]
TO
A MASTER OF THE OBSTETRIC ART
AND
AN ESTEEMED FRIEND,
^llW00tt mtiXson, pC.p.,
THESE PAGES ARE
RESPECTFULLY INSCRIBED.
CONTENTS
PAGE
Introduction, 11
PART I. — The Mechaxism of Labor.
Section 1. Th^ftnatomy of the Pelvis, . . . .15
Section 2. The Propelling Forces, .... 34
Section 3. The Body to be Propelled, . . . .39
Section 4. The Mechanism of Delivery, ... 45
I. The Vertex. 1. In the First Position, . . 46
2. In the Second Position, . 65
3. In the Third Position, . . 66
a. First Mechanism, . 67
b. Second Mechanism, . 72
c. Third Mechanism, . 73
d. Fourth Mechanism, . . 76
4. In the Fourth Position, . 78
II. The Face. 1. In the First Position, . . 81
2. In the Second Position, . 85
3. In the Third Position, . . 85
4. In the Fourth Position, . 87
PART IL— The Forceps.
Introductory 91
1. The Blades, 94
a. Head Curve, 95
b. Pelvic Curve, 97
2. The Handles, 99
3. The Lock, 100
8 CONTENTS.
PAGE
The Application of the Forceps, . . . .103
I. At the Inlet, 104
II. At the Outlet, ...*... 117
III. On the After-coming Head, .... 118
IV. General Remarks, 119 U
Traction, 121
Compression, 134
Leverage, 135
a. Flexion, ^^. . . 140
h. Rotation, ' . .142
When to Use the Forceps, . . . . . , 146
I. During the Second Stage, .... 147
II. During the First Stage, 160 ^
III. For certain Accidents of Labor, . , . 164
IV. For Secondary Purposes, 165
V
PREFACE.
The views herein set forth of the Anatomy of
the Pelvis were imperfectly outlined in an article
published in The Ainerican Journal of the Medical
Sciences for April, 1876. Further study and expe-
rience in teaching have led to their expansion into
what is now, I trust, a more exact and intelligible
statement. The practical deductions which arise
from them are given with as much conciseness as
possible.
It has not been thought necessary to present an
array of authorities and opinions of others as to
the manner of using the Forcejis when the stand-
point of observation was obviously different. With
this disclaimer of improperly ignoring the labors of
others in this field, these pages are submitted to
the profession for ^ the test of an enlarged experience.
H. G. LANDIS.
Columbus, 0., Sept., 1880.
*t
*
INTRODUCTION.
The right use of the obstetrical forceps demands
a thorough knowledge of four things : First, of the
instrument itself, its form, design, and capabilities ;
second, of the place into which it is to be intro-
duced, viz., the maternal passages, their form, direc-
tion, and mutual relations ; third, of the body upon
w^hich they are to be applied, viz., the child's head,
its form, consistence, and tolerance of manipulation ;
fourth, of the normal mechanism of labor, or the
manner in which the child should be delivered by
the natural powers — for the forceps are not a foreign
and unnatural resort, like the Csesarean section, but
are intended to assist, supplement, and conform to
the course naturally observed in labor. The great
diversity in the shape and design of forceps now in
use, and the vague and conflicting opinions as to the
manner of their employment are a sufficient evidence
that an exact and scientific basis has not yet been
reached or, if known at all, that it has not been well
and generally understood. A study of the mechan-
ism of labor de novo, will be, then, the first requisite
for a proper understanding of any artificial aid in-
tended to assist or replace that mechanism. I shall
take for granted a preliminary acquaintance with the
superficial anatomy of the pelvic bones.
PART I.
The Mechanism of Labor.
SECTION I.
THE AXATOMY OF THE PELVIS.
The mechanism of labor is concerned with three
things. 1. A body to be propelled. 2. A tube or
channel through which it is propelled. 3. The for-
ces which accomplish and regulate the propulsion.
The first is the child, and chiefly the child's head,
which alone offers much resistance. The second is
contained mainly in the pelvis. The third is mainly
of muscular origin. The relations which these sev-
eral factors bear to each other, and especially those
subsisting between the first and second, constitute
the most important part of the study of this mechan-
ism. Neither of these can be profitably studied apart
from the other except in so far as they may present
conditions alien to the mere fact of delivery. As a
starting-point we may take the most permanent fac-
tor, the pelvis.
The female pelvis has three uses :
I. It serves to contain and protect certain vessels
and viscera.
II. Being placed at the end of the vertebral col-
umn it is designed to support the weight of the body,
16 HOW TO USE THE FOKCEPS.
transmitting it to the femora in the erect position
and to the ischiatic tuberosities in the sitting posture.
III. It is modified to allow and direct the passage
of the child through it during labor, and is the prin-
cipal constituent of the parturient canal. The first
use is obvious, and is not relevant in this connec-
tion. The second is not entirely relevant, and may
be dismissed with this brief formulation, which the
practically minded reader may omit.
1. The pelvis is made up, first, of two beams, the
sacro-iliac, extending laterally from the base of the
vertebral column to the acetabulum of either side
and thus distributing the weight of the body to the
' femora in the erect posture.
2. These lateral beams are continuous with' a
third beam, the piilic, placed transversely, and in
front, which regulates the interval between them.
3. These three beams in the adult female are
arched outwardly to provide room for the parturient
act, and are so situated as to form a complete bony
rim at the beginning of the pelvis.
4. From the under side of this rim two other
arched beams spring, the ilio-sciatic, one on each
side and posteriorly, which end in the ischial tuber-
osities, to which they transmit the weight of the body
in the sitting posture.
5. A sixth arched beam, the siil-puhic, is placed
under the bony lim in front, which also has its ex-
tremities in the ischial tuberosity of either side.
THE ANATOMY OF THE PELVIS. 17
6. The upper bony rim is amplified into a tube by
the presence of these secondary arched beams on the
front and sides, and by the extension of the sacrum
and coccyx behind.
Thus we see that the pelvic tube is not entirely
designed as a parturient canal, but that a structure
having other uses has been modified for this second-
ary purpose. The extent of the modification can be
seen by comparing the male and infantile pelves with
Fig. 1.— Outlined from Hodge.
that of the adult female, the beams of the former be-
ing nearly straight, while those of the female are
greatly arched. And if it is modified for the sake of
the child, we may expect to find a correspondence
between the shape of the pelvis and the shape of the
child. Before making the comparison, we will no-
tice that the wings of the ilium and sacrum are con-
cerned only with the first and second uses of the
pelvis, being buttresses of the arched beams and
guards of the viscera against external violence. The
18
HOW TO USE THE FORCEPS.
Fig. 2.
obstetrical relations of the pelvis begin with the bony
rim before mentioned. We may therefore remove
these wings as a
preliminary to our
study. When the
sacral and iliac
wings, or ^' false pel-
vis," are removed,
the pelvis presents
the appearance
shown in Fig. 1,
when viewed from in front. If we then make a
perpendicular section through the acetabula we shall
find that the pelvic tube has an outline similar to
that shown in the diagram Fig. 2. It is therefore
wider above than below, which is the first important
fact to remember.
This does not give
us a complete idea of
the tube, for the sac-
rum which forms its
posterior wall is
markedly curved.
We must therefore
make another per-
pendicular section at
right angles to the
former one, which will give us such an outline as is
shown in Fig. 3. By combining these mentally, for
Fig. 3.
THE ANATOMY OF THE PELVIS. 19
obviously no pictorial representation can show tliem
at once, we will begin to have an approximate
idea of the shape of the pelvic tube. But we
would, if we stopped here, have an idea that it
resembled a funnel bent upon itself, and would
fail to have any explanation why the child in labor
does not at once drop to the bottom, since the
top of the funnel is so much more cajDacious than
the lower end. From these two sections we learn
coccyx
Fig. 4.— The Pelvic Inlet. Fig. 5.— The Pelvic Outlet.
only the direction of the tube ; its calibre must be
determined by looking into and through it. Its be-
ginning or inlet is found to have the shape indi-
cated in Fig. 4 ; its outlet, that shown in Fig. 5, a
remarkable difference. These four figures (2, 3, 4,
5) show the pelvis from in front, from the side, the
inlet and outlet, and must be held in mind while we
seek for a something to harmonize and explain them.
Beginning with the inlet, we find thai its shape
is often spoken of as an irregular oval, but when
20 HOW TO USE THE FORCEPS.
we analyze it we will find that it is beautifully
regular in outline. The explanation of its shape
must be sought, as said before, in the child, for
which the j)elyis has been modified. Clinical expe-
rience teaches us that the child's head is the part
which offers the most resistance in delivery. Its
great relative size and firm organization make it the
most difficult part to be expelled. Also, it is usually
in advance, and after its passage through the pelvis
the re^t of the body can readily follow. Next to the
head the shoulders offer the largest outline. Only
under exceptional and abnormal circumstances do
any other parts of the child present any difficulty in
passing through the joelvis. The natural manner for
the child to enter the pelvis in labor, is with the top
of the head in advance.
The middle circumference of the head is there-
fore applied to the brim or inlet at the beginning of
labor. If a plane section be made
through the middle of the head
horizontally and at the level of
the parietal eminences, it will be
bounded by such an outline as is
shown in Fig. 6, which is for all
practical purposes an ellipse. As
a matter of fact, if the head is
Fig. 6.— OuTLmB op
Foetal Head. partially flcxcd upou the brcast, a
horizontal section made at the same level will be
entirely elliptical. If we apply an ellipse cut out of
THE AX ATOMY OF THE PELVIS. 21
card-board and having such an outline, to the inlet
of the pelvis we will find that it completely coincides
on one side, and if reversed, to the opposite side, the
two outlines intersecting one another. This is shown
in Fig. 7, where the
dotted line A B finishes
the elliptical outline on
one side and the line
A 0 upon the other side.
The same ellipse applied
to the outlet entirely
corresponds to it, though
the outward flaring of the ischial tuberosities makes
this a little wider.
We may then say, tentatively, that the outline of
the inlet is compounded of two partially superim-
posed ellipses similar to the outline of the foetal head
— while the outlet represents but one such outline.
The shoulders will throw more light upon the sub-
ject. They also have upon transverse section an el-
liptical outline almost identical with that of the head.
But the long diameter of the shoulders, z.e., their
breadth, is at right angles to the long diameter of
the head. Therefore, when these two ellipses are su-
perimposed, as happens practically when the shoul-
ders follow the head through the pelvis, their outline
would present such an appearance as is shown in
Fig. 8.
This is not the whole truth. The foramen mag-
22
HOW TO USE THE FORCEPS.
num, and therefore the occipital condyles, are not
placed centrally in the base of the child's skull, but
much nearer the posterior end of the head, especially
Fig. a
Fig. 9.
when the head is flexed. Therefore, Fig. 9 may be
substituted for Fig. 8 as more exactly representing
the facts. Now if the head is laterally flexed so as
to bring one ear nearer to the corresponding shoulder
than in the horizontal position, which also happens
during the labor, these outlines would be superim-
FiG. 10.
Fig. 11.
posed in the manner shown in Fig. 10, which also
represents the outline of the pelvic inlet (Q.E. D.).
The length of the pelvis is such that the shoulders
THE ANATOMY OF THE PELVIS.
23
may still remain in the upper part when the head is
born. If it were not for some such provision the
neck would be disagreeably twisted, by reason of the
shoulders being compelled to follow the head through
a passage calculated for the latter alone. Further-
more, transverse sections of the pelvic tube made at
any point will show this double relation until we
reach the outlet, where
there is evidently but a
single canal. Fig. 11
shows the outline of
the canal a little above
the outlet. By the time
the shoulders have
reached this point the
head is born.
We may therefore
infer that the pelvis is
in reality a double canal,
its two parts being par-
tially fused at the be-
ginning and entirely so fig. 12.
at the end, and may construct a theoretical diagram,
Fig. 12, which will exhibit these facts. This will
explain the appearance delineated in Fig. 2, for on
adding dotted lines to represent the inner and in-
visible walls of these supposed parts, as in Fig. 13,
we see why the pelvic inlet is wider than the outlet,
and also learn the direction of the two canals.
24
HOW TO USE THE FORCEPS.
These facts may be formulated as follows, before
proceeding further, with such conclusions as may
warrantably be drawn from them.
I. The pelvis contains two canals, partially sepa-
rate at the beginning and identical at their termina-
tion.
II. These canals converge from above downwards,
and are also mutually curved from before backwards,
as indicated in Fig.
3. Their direction
is therefore some-
what spiral.
III. The calibre
of each canal is that
of the foetal head ;
therefore the head
may descend in
either canal and will
follow a spiral course in so doing. These canals may
be called respectively the right and left canals ; the
right being the one in which exclusively the right
sacro iliac symphysis is found, and the left in which
the left sacro iliac symphysis is found. Of these the
right is somewhat the larger and is the one in which
the head usually descends ; for which there are other
reasons, as will be shown further on.
For purposes of description certain planes, axes,
and diameters are to be considered, concerning
which we will first state the views generally enter-
THE ANATOMY OF THE PELVIS.
25
tained. Playfair says :* ^^ By the planes of the pel-
vis are meant imaginary levels at any portion of its
circumference. If we were to cut out a piece of
card-board so as to fit the pelvic cavity, and place it
at the brim or elsewhere, it would represent the pel-
vic plane at that particular part, and it is obvious
that we may conceive as many planes as we desire."
Two such planes are of especial importance, those of
the inlet and outlet,
or, as they are also
termed, the superior
and inferior strait.
Hodge defines the
plane of the superior
strait as a surface
bounded by the cir-
cumference of the
strait which is marked
by the ** inner margin
of the tuberosity or
horizontal portion of the pubes on either side, by the
spinous process, the linea ilio-pectinea, and the inner
margin of the ala of the sacrum, and posteriorly by
the promontory of the sacrum.'^ The axis of this
plane is a line drawn at right angles to it and the
combined axes of similar planes drawn at all levels of
the pelvic cavity, constitutes the axis of the pelvis,
which is supposed to indicate the course of the
child's head in delivery (see Fig. 14).
* System, p. 35-6.
Fig. 14.
26 HOW TO USE THE FORCEPS.
By beginning wrong we generally end wrong.
By studying the pelvis only from antero-posterior sec-
tions we get only a partial knowledge of it. The
whole study of the mechanism of labor as given by
Hodge and his successors is vitiated by the inac-
curacy involved in his description of the superior
strait. For to this succeeds, as a consequence, a
vagueness as to the true position of the head in labor
— which is a point of great practical importance, es-
pecially when we attempt to apply the forceps. To
begin on common ground, the plane of the inferior
strait is confessedly artificial and arbitrary. The
outlet is so irregular in its termination that no one
pretends to describe a plane passing through all the
points of its circumference. We draw a line from
the under edge of the symphysis pubis to the tip of
the coccyx, called the conjugate diameter of the out-
let, and a plane passing transversely through this line
and limited by the calibre of the pelvis, we call the
plane of the inferior strait. Since this calibre is so
evidently the same or nearly so as that of the foetal
head, and since we find clinically that the head
emerges from the outlet in a definite relation with
such a plane, we may retain it, but always admitting
its artificial character and boundary. The same
course has not been followed with the inlet. Ilodge
gives no hint of compromise in fitting the plane of
the superior strait in its circumference, although
Fig. 1, outlined from his work, shows clearly enougli
THE ANATOMY OF THE PELVIS. 27
that no plane can pass through the points mentioned
in his definition. And as unnoticed error, especially
when sanctioned by high authority, has a great power
of growth, it is not surprising to find Dr. Leishmann
following with the statement that the yarious parts
of the line bounding the superior strait '^are in
man alone on the same plane. ^' As a matter of fact,
the circumference of the inlet bounds two distinct
planes, whose inclination to each other may be seen
in Figs. 1 and 2 to be about at an angle of 150°.
If we cut out of card-board two ellipses similar in
outline to the middle circumference of the foetal head
and apply them or attempt to apply them to the
border of the pelvis on each side — in other words to
the very points mentioned above by Hodge — we will
find that they intersect one another in the median
line, while accurately fitting the pelvis in other re-
spects. We may call these planes respectively the in-
itial plane of the right and left canal. Any number
of similar planes may be drawn in each canal, which
will have a less and less inclination to each other
until at the inferior strait they will be identical with
each other and with the plane of the inferior strait
as above described. The axis of the initial plane of
either canal is a line drawn at right angles to that
plane, and indicates the direction of either canal at
the beginning.
The axis of each canal will be a line extending
from the centre of its initial plane centrally through
28 HOW TO USE THE FORCEPS.
the canal to the centre of the j)lane of the inferior
strait. This line will not have only the direction
shown in Fig. 13, but being curved from before back-
wards, in the manner of the central axis in Fig. 14,
will be spiral and therefore incapable of pictorial rep-
resentation. But there is upon the pelvic walls a
line on either side, which is as nearly as possible par-
allel to this axis, viz., the raised line extending from
each pectineal eminence on the ileo-pectineal line to
the ischial spine of the same side. As this is an im-
portant line from this circumstance, and from the
part it plays in the mechanism of labor, we may give
it a name and call it the ilio-sciatic line.
It will be convenient for descriptive purposes to
retain the so-called ''plane of the superior strait,''
but for avoidance of confusion we may define it as
passing transversely through the conjugate diameter
(CD, Fig. 15) of the inlet and call it the plane of the
cojijugate diameter. Similar planes may be conceived
of as drawn at right angles to the general cavity of the
pelvis at any level, and to distinguish them from like
planes drawn in the right and left canals we may call
them planes of the pelvic cavity. The plane of the
conjugate diameter is said to be inclined to the liori-
zon at an angle of 60° when the woman is in the
erect posture, tlie face of the pubes looking almost
directly downward and the plane of the outlet back-
wards and downwards. In the sitting posture, with
the pelvis resting on the tuberosities of the ischia, the
THE ANATOMY OF THE PELVIS. 29
inclination of the plane of the conjugate diameter is
about 45°, while the plane of the outlet is almost hor-
izontal and looking directly downwards.
In the recumbent posture the plane of the conju-
gate diameter is almost equally inclined in an oppo-
site direction from the last, the plane of the outlet
being nearly vertical. In the semi-recumbent pos-
ture, which is supposed to be the characteristically
American method of sitting, the plane of the conju-
gate diameter is level with the horizon, while that of
the outlet looks downwards and forwards. The in-
itial planes of the right and left canals have substan-
tially the same inclination to the horizon as the plane
of the conjugate diameter in these various positions,
so far as the planes are considered in their antero-
posterior direction. But they have also a lateral
obliquity of about 15° from that of the conjugate di-
ameter, which is made sufficiently evident by refer-
ence to the figures or better still, to the pelvis itself.
Certain diameters are usually described as existing
in the inlet and outlet of the pelvis.
The principal ones in the inlet are the two ob-
lique diameters and the conjugate. The oblique
diameters are drawn from the sacro-iliac symphysis
of either side to a point slightly in advance of the
pectineal eminence of the opposite side (Meadows).
In Fig. 15, AB represents the right oblique diameter
(according to the German nomenclature), and EP,
the left oblique. If we apply to the inlet a piece of
30
HOW TO USE THE FORCEPS.
card-board cut after the pattern of the elliptical out-
line of the foetal head, as delineated in Fig. 6, we
will see that the long diameter of such an ellipse cor-
responds with the oblique diameter of the canal in
which it is inserted, while the short diameter of the
ellipse lies in the line of the opposite oblique diam-
eter. These diameters are nearly or quite five inches
long in the normal pelvis,
and are longer than any
other which can be drawn
in the pelvic brim, except
in some cases the one ex-
tending directly across it
and known as the trans-
verse diameter. The
conjugate diameter CD is
drawn from the promontory of the sacrum to the
middle of the top of the symphysis pubis, and is the
shortest, being about four inches in the normal pel-
vis. Two others should perhaps be mentioned here,
which are the ones drawn across the base of each
sacro-iliac arch and called the sacrO'Cotyloid.
Apart from any consideration of the doubleness
of the pelvis, it is generally recognized that the head
will enter the inlet with the greatest economy of
space when its long or occipito-frontal diameter co-
incides with one of the oblique diameters of the pel-
vis, while its transverse or short diameter has an
equal amount of room in the opposite oblique diam-
THE ANATOMY OF THE PELVIS. 31
eter. At the outlet the antero-posterior or conju-
gate diameter extends from the under edge of the
pubes to the tip of the coccyx, but a little reflection
shows that it is the representative of the upper
oblique diameters. Thus, if a rod be placed in the
inlet coincident with the right oblique diameter, and
its central point carried downwards in the axis of the
right canal, its posterior extremity will traverse a
line from the right sacro-iliac symphysis to the tip
of the coccyx, while its anterior end will follow a
similar line from a point in front of the left pecti-
neal eminence to the centre of the under edge of the
symphysis pubis, and the rod will then lie in the
conjugate diameter of the outlet. For the rod,
substitute a foetal head with its long or antero-pos-
terior diameter in coincidence with the right oblique
diameter of the inlet and the correspondence of the
head to the right canal throughout will be entirely
manifest. The same may be affirmed of the left canal,
with a corresponding change of right to left, and so on.
The bony pelvis, with its ligamentous and mus-
cular additions, does not comprise the whole of the
parturient canal, but at the inferior strait begins that
part of it which is made up only of the soft parts.
The latter is only temporarily fitted for this use, and
has no fixed calibre, axis, or diameters, which are
regulated by the size and shape of the foetal head
and the direction taken by it. It is enough at pres-
ent to conceive of it as an elastic tube through which
32
HOW TO USE THE FORCEPS.
the nead passes after being delivered from the pelvic
canal. Besides the soft parts at its termination the
uterus also may be said to form a part of the partu-
rient canalj since the child in passing out of it must
have its original direction controlled to a great ex-
tent by the position of the uterus. The uterus, dur-
ing labor, is not placed directly in the median line.
B
Fig. 16.
From various causes, among which the prominence
of the lumbar vertebrae is conspicuous, it is some-
what deflected towards one side or the other of the
median line, and in the majority of instances towards
the right side. Viewed laterally the womb appears
THE ANATOMY OF THE PELVIS. 33
to be situated with its axis in the same line with that
of the plane of the conjugate diameter. This is the
statement usually made ; but when we perceive this
obliquity we recognize that this cannot be^ and that
the axis of the uterus in labor is in the majority of
instances continuous with the axis of the initial plane
of the right canal (see Fig. 16).
If, then, the child is disposed in the womb with its
long axis coincident with that of the womb, it will be
situated in the most favorable manner for entering
the right canal. And the same might be affirmed of
the left canal if the womb was in a condition of left
obliquity. Since it is rarely found in this condition,
and since we find clinically that the head is found
with similar infrequency in relation with the left
canal, we derive additional proof of the doubleness
of the pelvis and of the existence of such planes and
axes as have already been described.
SECTION 11.
THE PROPELLING FORCES.
The forces concerned in the mechanism are of
two kinds, propulsive and guiding. The former are
furnished by the contraction of the uterine muscular
fibres and by the voluntary and semi-voluntary con-
tractions of the abdominal muscles, but not exclu-
sively. The force of the uterine contractions is
communicated to the vertebral column of the chlid
and acts primarily in the long axis of the womb.
They therefore tend to propel the child in the axis of
the initial plane of the right canal in the majority of
instances ; or when the womb has a left obliquity in
that of the opposite canal. So far as the uterus is
concerned, therefore, the child tends to move through
the pelvis in the direction of the line AB, in Fig. 16.
The abdominal muscles transmit force in the same
manner to the child, but in the median line when
they act uniformly. Hence they are well designed
to propel the child after it has reached the inferior
strait and has finished its oblique course in the right
or left canal. And as a clinical fact, we find that
the action of the abdominal muscles is not, as a rule,
THE PROPELLING FORCES. 35
called into effect until tlie head has attained this
stage. But from the inclination of the pelvis to the
vertebral column, each of these forces, the uterine
and abdominal, tends to propel the child to points
behind the centre of the plane of the outlet. The
abdominal muscles acting primarily in the axis of the
plane of the conjugate diameter, impel it towards
the tip of the coccyx. The uterine force tends to
impel it to the same point ; perhaps a little to one
side, but as far back.
These tendencies are modified by the directive or
guiding forces reflected from the sides of the canal,
which being spiral or screw-like in shape consist es-
sentially of continuous inclined planes. From the
pelvic outlet to the vaginal outlet the head follows a
very different course, emerging from the latter in a
direction which forms an acute angle with the pro-
duced axis of the plane of the conjugate diameter.
It is obvious that the same force cannot act in two
directions, one of which is almost the reverse of the
other. There must be, then, a new force beyond the
pelvic outlet acting in a different direction. This
we find in the perineum.
The superficial or anatomical perineum is the
space bounded between the posterior vaginal commis-
sure, the anus, and the ischial tuberosities. The
deeper structures of this area consist of certain mus-
cles and fibrous tissue, and most important of all,
the perineal body. They are placed in front of or
36
HOW TO USE THE FORCEPS.
opposite to the pelvic outlet, constituting the floor of
the pelyis. The mechanical action of the whole
structure may be studied in that of its principal
part. The perineal body is a stout fibrous band ex-
tending from one tuber ischii to the other. It is
made of elastic fibrous tissue, and both for strength
and elasticity is comparable to no other tissue of the
Fig. 17.
body unless perhaps the ligamentum nuchse. On sec-
tion it appears wedge-shaped, being inserted between
the vagina and rectum at their termination, with the
edge directed upwards. It extends backwards as far
as the coccyx — being covered and supplemented by
sundry muscles of more or less importance in this
connection, but having substantially the same me-
chanical purpose in labor.
THE PROPELLIJTG FORCES. 37
When the combined propulsive and directing
forces have brought the head to and nearly through
the pelvic outlet, it is met by the opposiug force ex-
isting in the elastic resistance of the perineal body
assisted by the associated structures of the pelvic
jBloor. The latter force acts in a direction nearly
opposite to the former, and the head is, therefore,
directed forward in the line of the resultant of the
two forces. In Fig. 17 the arrow A represents the
direction in which the original forces bring the head
upon the perineum : B will represent the line of the
direction impressed upon the head by the perineal
force alone, and C will show the resultant of the two.
The important practical bearing of this will be noted
in the proper place. Another force may assist in de-
livery, viz., gravity. The amount of force employed
in truly normal labor is not great.
The following, from J. Matthews Duncan (Re-
searches, p. 319), will suffice to illustrate this point :
^' If we regard the figure of four pounds given by Pop-
pel as equal to the power exerted in the easiest labor
he has observed, or the corresponding figure of six
pounds, according to my calculations, and keep in
mind that the average weight of the adult fcetus ex-
ceeds either of these weights, we are led to the conclu-
sion that in the easiest labors almost no resistance is
encountered by the child ; that it glides into the world
propelled by the smallest force capable of doing so ;
that with the mother in a favorable position, the
38 HOW TO USE THE FORCEPS.-
weight of the child is enough to bring it into the
world — a result which many clinical facts at least ap-
pear to conBrm." The same author says also : '' Hav-
ing had extensive and varied experience in the use of
forceps in difficult labors, and having also made some
rough experiments with the dynamometer, to ascertain
the power I have applied by the instrument, I regard
M. Joulin's estimate of a hundred -weight, as the maxi-
mum force of the parturient function, as too high-
I do not deny that in very rare cases such a force
may possibly be produced, but I am sure that it is
nearer the truth to estimate the maximum expulsive
power of labor (including the uterine contractions
with the assistant expulsive efforts) as not exceed,
ing eighty pounds." In this opinion I entirely
agree, believing that the extreme efforts made in
some cases with the forceps are due to a misappre-
hension of the proper direction of force, rather than
to any need for such an amount of force.
SECTION III.
THE BODY TO BE PROPELLED.
The cliild for whose sake all this machinery is
ordered is, when packed in the womb, of ovoid
shape. At one end is the head, at the other the
similarly rounded breech. Like an egg, it is natural
for it to pass through the pelvis endwise, with one
end or the other in advance. As the head is freely
movable upon the neck and capable of considerable
extension, either the top of the head or the face may
be in advance. The child may also attempt to enter
the pelvis crosswise or transversely. We have then
four distinct methods of entrance. The part in ad-
vance at the beginning of labor is called the present-
ing part, and the area of this part inclosed by the
pelvic circumference is technically called i\iQ presenta-
tion.
There are therefore four distinct presentations :
I. of the top of the head, or vertex ; II. of the
Face ; III. of the Breech, and IV. Transverse.
The vertex presents in at least ninety per cent,
of all labors and is evidently the natural presentation
and the one for which the pelvis is specially de-
40 HOW TO USE THE FOKCEPS.
signed. I shall, therefore, confine my remarks to
this presentation, with a brief account of the second,
since the others are neither strictly normal nor suited
for the application of the forceps. Let us first re-
fresh our memories with some topographical anatomy.
Upon the top of the fcetal cranium appears a suture,
extending directly antero-posteriorly between the pa-
rietal bones, called the sagittal suture. At its pos-
terior limit is a triangular membranous interval call-
ed the posterior fontanelle or bregma. At its anterior
limit is a similar quadrilateral interval called the an-
terior fontanelle. From the posterior fontanelle a
suture extends on either side, joining the occipital to
the parietal bones of either side, the two being col-
lectively called the lamMoidal suture. From the
anterior fontanelle a suture extends in front which is
practically a continuation of the sagittal, called the
M-frontal suture. At right angles to it proceed from
each side of the anterior fontanelle, sutures joining
the anterior border of the parietal to the frontal
bone, which are together known as the coronal su-
ture. These fontanelles and sutures are of variable
size, being sometimes large and distinctly recogniza-
ble, in other cases small and indistinct. They are
also more or less obscured by the covering of the hairy
scalp.
During labor the sutures themselves are not so
apt to be felt as the overlapping edge of bone which
results from their approximation. Between the
THE BODY TO BE PROPELLED. 41
limbs of the lambdoidal suture, an inch or a trifle
more from the posterior fontanelle, is the occipital
protuberance, a prominent and useful landmark in
ascertaining the position of the head at times. Still
more useful are the parietal protuberances situated
nearly in the centre of each parietal bone. The
frontal eminences similarly situated in the frontal
bones are hardly to be felt except in face presenta-
tions or during the perineal stage of labor, and are
not usually of diagnostic importance. The ears are
scarcely ever within reach, still less the mastoid
prominences. Not infrequently the small fonta-
nelles at the postero-infcrior angles of the parietal
bones are within reach and are to be recognized by
the extension into them of the lambdoidal suture.
Certain planes and diameters are important for pur-
poses of description. When the head is placed in a
horizontal position quoad the body in the erect pos-
ture, a plane drawn transversely through the occipi-
tal and parietal protuberances will present an ellip-
tical outline as already delineated in Fig. 6. This
plane may be called, from its long diameter, the oc-
cipito-f7'ontaly the latter line extending from the oc-
cipital protuberance to a point, in the bi-frontal su-
ture. The transverse diameter is drawn from one
parietal protuberance to the other, and is called the
M-jjarietal. It will be observed that this outline is
not a perfect ellipse, the transverse diameter being
behind the centre, though this irregularity is less
42 HOW TO USE THE FORCEPS.
marked in the living head than in the dried skull.
The occipitO'frontal diameter measures on an average
a little more than four inches in length, the bi-pari-
etal about three and a half inches.
If the head is partially flexed, a similar trans-
verse plane passing through the parietal protuber-
ances will extend through the occipital ridge, or nape
of the neck, and the apex of the forehead, and may
be called the plane of demi-flexion. Its outline will
be almost exactly elliptical ; the transverse diameter
being the same as in the preceding plane, viz., the
bi-parietal, and its long diameter, the cervico-frontal^
will be a little less than four inches. If the head is
completely flexed, as when the chin rests upon the
breast, a similar plane drawn through the parietal
protuberances will pass through nearly the same
point posteriorly as in the last plane, viz., the nape
of the neck a little below the occipital ridge ; and its
anterior limit will be in the posterior margin of the
anterior fontanelle. Its outline will be nearly circu-
lar, for while the transverse diameter is still the bi-
parietal, its long diameter, the cervico-bregmatic, is
also three and a half inches long. This plane may
be called the plane of complete flexion. Its circular
outline is an important fact to bear in mind.
The conclusion is now apparent that flexion of
the head reduces the outline which it presents to the
pelvic passages. It is of interest to note the relative
position of the fontanelles during these changes.
THE BODY TO BE PROPELLED. 43
"When the occipito-frontal plane is horizontal the an-
terior fontanelle appears nearly in the centre of the
elliptical area above the plane, while the posterior
fontanelle is very near its posterior margin. When
the head is in demi-flexion the fontanelles appear
very nearly in the foci of the ellipse, and in complete
flexion the posterior fontanelle occupies the centre
of the circular area presented, while its fellow has
disappeared from view in front.
The outline of the foetal head is still further capa-
ble of being diminished by the overlapping of the
parietal bones, either by compression due to the
small size of the pelvic canal, or artificially by the
forceps. The bi-parietal diameter can be lessened
from a half inch to a full inch by such compression.
Not only can these diameters be compressed and
shortened by these agencies, but the entire shape of
the head may be changed by a process of moulding
during the process of expulsion.
The face of the child ojffers little to detain us at
this point. It is also of rather elliptical outline,
having a long diameter, i\iQ fronto-meiital, which ex-
tends from the chin to the top of the forehead ; and
a transverse diameter, the ii-malar, which extends
from one malar bone to the other. But these are so
much smaller than the diameters which lie behind
them in the head, that the face evidently offers no
diflBculties per se in delivery. The real difficulties
are due to the manner in which the bulkier posterior
44 HOW TO USE THE FORCEPS.
portion of the head and the body are made to enter
the pelvis when the face j)resents, and this can be
better described in connection with the mechanism
of labor in this presentation.
The lody of the child exhibits upon transverse
section an elliptical outline in its entire extent, and
especially at the level of the shoulders and breech.
As has already been noted, the long diameters of
such sections are at right angles to the long diam-
eters of similar sections of the head, and from the fact
that the foramen magnum is situated behind the
centre of the head, the body tends to follow the head
a little behind the central axis of the head.
SECTION IV.
THE MECHANISM OF DELIVERY.
Since there is an evident correspondence between
tlie pelvic canals and the head in their outline, it is
a natural inference that the occipito-frontal plane of
the head may enter either the right or left canal, and
in two ways : with its occipital extremity either in
front or behind. Clinical observation is usually in
advance of theoretical knowledge, as is conspicuously
shown by the fact that all recent writers agree in ad-
mitting but four positions of the vertex. And yet,
while the pelvic brim is considered as having an *' ir-
regularly oval outline,'' there is no obvious objec-
tion to the eight positions of the earlier authorities,
or indeed to any number whatever. It is only when
we find that it is of singularly regular outline, by an-
alyzing it, that we are compelled to see a theoretical
reason for the already clinically observed fact.
I. The Vortex.
The nomenclature of these positions is founded
on the position of the occiput, which will be situated
on one side or the other and in front or behind.
They are as follows :
46 HOW TO USE THE FORCEPS.
■
1. Left occipito-anterior,
2. Right occipito-anterior.
3. Eight occipito-posterior.
4. Left occipito-posterior.
1. The First or Left Occipito-Anterior Po-
sition (L. 0. A.) is the most frequent, occurring in
at least seventy per cent, of all positions of the ver-
tex. The reasons for its prevalence are to be found
in several combined causes. The folded-up attitude
of the child in utero requires that its back shall be
turned towards the mother's front. The prominence
of the vertebral column and more especially the sa-
cral promontory, will determine the position of the
occiput on one side or other of the median line.
Since the long axis of the child is correspondent
with that of the uterus, its head is placed directly
over the initial plane of the right canal, owing to the
usual right obliquity of the uterus. Also the right
canal is actually a little larger than the left, and the
latter contains under the left sacro-iliac arch the rec-
tum, which still further diminishes its size. This is
therefore the most natural and favorable of all the
positions.
At the beginning of labor the head in this posi-
tion is placed with its occipito-frontal plane coinci-
dent with the initial plane of the right canal. The
occipital protuberance is opposite a point in front of
the left acetabulum ; the bi-frontal suture is in front
THE MECHANISM OF DELIVERY. 47
of the right sacro-iliac symphysis, and the right par-
ietal protuberance is opposite a point over the right
obturator foramen towards its inner edge. The left
parietal protuberance is not opposed to any point of
the pelvic circumference, but is in the free space in
front of the left sacro-iliac symphysis. The occipito-
frontal diameter is therefore coincident with the
right oblique diameter of the pelvis. The head is
obliquely situated with reference to the plane of the
conjugate diameter, one side of the head being below
and the other above that level. This fact was first
noticed by Naegele, but stated too generally, since
this obliquity frequently and indeed usually disap-
pears in the succeeding stages. For as soon as the
uterine efforts become at all effective, the head un-
dergoes a compound movement by reason of which
its synclitismwith the initial plane of the right canal
disappears, and therefore its obliquity to the plane of
the conjugate diameter, while another head plane
than the occipito-frontal is made to engage by means
of flexion. The cause of this movement is to be
found principally in the unequal resistance offered by
the pelvic walls. The right parietal protuberance is
directly applied to the anterior pelvic margin, while
the left is entirely free, and the same may be said of
the entire right and left sides of the head, the protu-
berances being cited merely as the more prominent
parts. If the size of the head and the calibre of the
right canal are at all equal and the fit is tight, the
48 HOW TO USE THE FORCEPS.
right side of the head will meet with considerable
resistance to its onward motion communicated from
the uterine forces, and will, therefore, be arrested,
while the left side, being untrammelled, will descend.
There will result a lateral flexion of the head, which
will bring the occipito-frontal plane synclitic with
the plane of the conjugate diameter.
If the abdominal muscles are called into action at
this time, they will by their compression tend to
force the uterus backwards and so deflect its axis as
to still further impel the head against the anterior
pelvic walls, which will also assist in bringiug about
this lateral flexion and the resultant synclitism.
This synclitism is in reality an obliquity of the foetal
planes to the transverse planes of the right canal,
and continues throughout the further progress of
the head, being indeed necessary when the head has
reached the inferior strait. Before that point it does
not invariably occur. The relative size of the head
may be small, and it may continue in exact relations
with the successive planes of the right canal through-
out, as was practically the teaching of Naegele. But
inasmuch as the head is usually large enough to offer
an appreciable amount of resistance, the synclitism
of the presenting plane of the head with the artificial
planes of the pelvic cavity is the rule rather than the
exception. This has led Cazeaux, Hodge, Leish-
mann, and others to entirely combat the obliquity of
the head at any time, which is an error in the oppo-
THE MECHANISM OF DELIVERY. 49
site direction, since it must originally exist from tlio
manner in which the head enters the inlet.
A similar cause to that which determines the lat-
eral flexion of the head brings about at the same time
flexion proper, or the movement of the chin towards
the breast. Although the right oblique diameter
with which the occipito-frontal is coincident is five
inches long in the bony pelvis, the soft parts so di-
minish the size of the canal that some lessening of
the head outline, especially in its lengtli, is usually
necessary. The head may be regarded as a lever at-
tached to the vertebral column as a fulcrum. The
resistance which it encounters causes the anterior
joart of the head, v/hich is the long arm of the lever, to
be flexed towards the chest. Also, the occipital end
of the head is in the anterior and roomy part of the
pelvis, and thus more free to move than the frontal
end, which is cramped by the narrower dimensions of
the right sacro-iliac arch.
This flexion continues until the head j)resents an
outline small enough to pass readily, which usually
happens when the plane of demi-flexion has become
coincident with the plane of the conjugate diameter,
or, to speak more accurately with a plane parallel to
the latter, but a little lower in the pelvis. If the
plane of demi-flexion presents too large a circumfer-
ence, flexion continues until complete. If then there
still remains any disproportion between the head and
pelvis, the force is exerted upon all the diameters of
50 HOW TO USE THE FORCEPS.
the head, which is diminished in size by a general
compression. From this results what is known as
the moulding of the head, which so rearranges its
shape that its. original outlines are entirely changed
and it becomes cylindrical. This, if successful, is
continued until the diameters of the head correspond
to those of the pelvic canal. I believe that this head-
moulding often occurs at an earlier stage from a fail-
ure of the head to properly undergo flexion, and
that a thoroughly flexed head is rarely in need of any
further diminution of its outline. Ordinarily the
plane of demi-flexion will have a sufficiently small
circumference, and the head is then ready to descend.
The flexion of the head may and generally does
occur before the os uteri is fully dilated. When this
is completely effected the head at once descends with
the plane of demi-flexion constantly synclitic with
the successive artificial planes of the pelvic cavity.
As it descends, it simultaneously rotates upon its axis,
the occipital protuberance coming nearer and nearer
to the median line in front and the bi-f rental suture
similarly approaching the median line behind. The
course of the head is at first downwards, backwards,
and inwards, following spirally the course of the axis
; of the right canal. The backward direction is soon
changed to a forward one as it descends, but is im-
portant while it lasts. Mechanically speaking, the
uterine force is reflected from the pelvic walls so as
to guide the head and induce this result, All parts
THE MECHANISM OF DELIYEKY. 51
of the pelvic wall share in guiding the head, but the
right ilio-sciatic line is especially effective. The
riglit joarietal protuberance is constantly in advance
of this line, which has therefore a similar action.
to the rifling in a gun-barrel. The left pari-
etal protuberance is remote from the left ilio-
sciatic line, and crosses it during the movement
of rotation before it is brought into very close rela-
tions with it. The rotation of the head ceases when
it reaches the inferior strait, with the parietal protu-
berances in front of the ischial spines and its antero-
posterior diameter in the median line, the plane of
demi-flexion being completely coincident with the
plane of the outlet. The ischial spines, which are
the continuation of the ilio-sciatic lines, are nsually
more projecting than any other part of the latter.
The inferior strait is therefore well named, being the
narrowest part of the pelvis as well as the end of the
double tube.
A slight delay is apt to occur here, during which
the movement of flexion is continued, if necessary,
until the plane of complete flexion becomes coinci-
dent with the plane of the outlet, after which the
propulsion of the head is resumed. The subsequent
course of the head is through the single tube formed
by the soft parts, and might with propriety be set
apart as a distinct stage of labor — the perineal stage
— since a new force is here called into operation.
Before describing it, I will call attention to a few
52 HOW TO USE THE FORCEPS,
points in which, the foregoing acconnt differs from
the received teaching upon this subject. Hodge,
whose exposition of the mechanism of Labor is the
most complete extant, states'^ that the central por-
tion of the child's head describes in its descent the
axis of the general pelvic cavity. This axis extends
centrally through the pelvis downwards and. back-
wards (afterwards forward), following the curve of
the sacrum. The axis of the right canal, in which
it is here asserted that the centre of the child's head
moves, extends spirally downwards, backwards, and
inwards. If a piece of card-board be cut out, of el-
liptical outline, similar to the outline of the occipito-
frontal plane, or the plane of demi-flexion, and ap-
2^1ied to the pelvic inlet, so that its long diameter
corresponds to the oblique diameter as already de-
scribed, the centre of the ellipse will be found to bo
at quite an appreciable distance to the right of the
median line. But if the ellipse is placed in the pel-
vic outlet in the same manner as the head occupies it
during labor, its long diameter, and therefore its cen-
tre, will be exactly in the median line. Therefore in
moving from the superior to the inferior strait the
centre of the head moves towards the median line, or
inwards, as does the axis of the right canal.
As a necessary concomitant or preliminary to this
inaccuracy of the existing doctrine, some vagueness
of expression concerning the true position of the
* System, p. 30.
THE MECHA]S'ISM OF DELIVERY. * 53
head at the inlet will be found, for if the latter
had been accurately noted, it would at once have
been manifest that the head does not occupy the in-
let centrally. The same author states/*' '^ In the
first position of the vertex, after flexion has been per-
fected, it is strictly correct to say that the nape of
the neck, or sub-occipital region, is opposite the left
acetabulum, and the anterior fontanelle to the right
sacroiliac symphysis ; while the right jDarietal pro-
tuberance is to the ri2:ht acetabulum and the left to
the left sacro-iliac symphysis." These four points,
the parietal protuberances, occipital protuberance,
and anterior iontanello, are about equidistant. A
head which has its occipital protuberance ojoposito
one acetabulum and its right parietal protuberance
opposite the other acetabulum, would, if finished
upon the same magnificent scale, be difficult to place
in the human pelvis. The correct position is stated
on pages 46-47.
The importance of accurate discrimination in
these points Avill be more apparent in connection with
the application of the forceps. It is sufficient to
note here that the head, not being placed centrally,
leaves quite a large free space in front of the left sa-
cro-iliac symphysis.
As the head passes through the inferior strait, and
even a little before, it begins to encounter the re-
sistance of the pelvic floor, against which it is pro-
* Op. Cit., p. 148.
5i HOW TO USE THE FORCEPS.
pelled. This brings to bear upon it the force de-
scribed at page 37. Assuming that complete flexion
has taken place at the outlet^ as is customary, the
plane of complete flexion is coincident with that of
the outlet. As the head is propelled forward in the
line of the resultant of the two forces, the plane of
complete flexion continues to maintain its coincidence
with the successive transverse planes of the parturi-
ent passage. The flexion of the head is, however,
not kept up, but extension occurs progressively dur-
ing the remainder of its course.
The movement of extension is readily seen to be
somewhat different in its results from the mere re-
versal of flexion. This is due to the different cir-
cumstances under which the movements take j)lace.
Flexion at the inlet resulted in bringing new planes
of the head in relation with the pelvic planes, and
the same is true throughout the pelvis. But the ex-
tension which occurs after the passage of the inferior
strait has no such displacing effect, the cervico-breg-
matic diameter continuing to coincide with the an-
tero'posterior diameter of each successive jolane of
the passage. Extension occurs because of the great
curvature of the canal at this point, which takes a di-
rection almost opposite to that of the bony canal.
This necessitates a bending of the projectile upon it-
self, since the body cannot at once be dragged down
with the head. This movement keeps the smallest
attainable outline of the head in relation with tlie
THE MECHANISM OF DELIVERY. 55
vaginal tube. The sub-occipital region remains un-
der the sub-pubic arch, while the forehead and face
sweep over the perineum. The perineum becomes
greatly distended and changes its shape. It is, as be-
fore noted, wedge-shaped or triangular upon section,
the apex of the triangle being at the verge of the
anus. As the head glides upon and over it the apex
of the triangle moves forward and a large portion of
the anterior wall of the rectum is added to the peri-
neal surface.
It is very necessary to remember this forward
motion of the perineum in any attempts to assist the
natural mechanism. As the head escapes from the
vulvar orifice the perineal tissues retract to nearly their
original condition, chiefly by reason of their inherent
elasticity, aided somewhat by the action of the trans-
verse muscles of the perineum. The vulva will then
embrace the child's neck, while the head, released
from the tube, is again flexed. So far as the forceps
are concerned, we might here suspend the account of
the mechanism of labor, but for the sake of com-
pleteness and for the light which may be thrown on
the foregoing stages, we will continue it. At the
moment of birth the head was propelled almost ver-
tically upwards (the woman being upon her back),
while the body remains behind and in a general way
at right angles to the long diameter of the foetal
head. Hence the flexion or dropping of the chin
when the head is born. A lateral movement is also
56 HOW TO USE THE FORCEPS.
described, called restitution, in wliicli the head turns
obliquely after birth, with the occiput in front and
to the left, as when at the inlet.
This is of little imj)ortance, nor does it always oc-
cur, since it depends upon the manner in w^hich
the body conforms to the mechanism by which the
head was delivered. As the head passes the inferior
strait the shoulders enter the pelvis if the neck is of
its ordinary length. As already noted, their proper
method of entrance is with their long or bis-acromial
diameter coincident with the left oblique diameter of
the inlet, and their elliptical outline in connection
with the beginning of the left canal. This is tlie
natural provision ; after wliich they descend in that
canal, rotating in the oppositcdirection to that which
the head followed. After the delivery of the head
they arrive at the inferior strait with their long di-
ameter in the median line and the right shoulder in
front. Circumstances cause this mechanism to be
often varied fi'om. The mobility of the neck and its
varying length do not render it absolutely necessary
that the shoulders should follow the rotatory move-
ments of the head or be affected by them. Per con-
tra, the shoulders may be prematurely and unduly
influenced by the head rotation. Hence, when the
head has assumed its directly antero-posterior posi-
tion at the inferior strait the shoulders may have
been comi)elled to engage in the inlet with tJieir long
diameter directly transverse and thus out of relation
THE MECHANISM OF DELIVERY. 57
with either canal. Since they have not the solid and
comparatively unyielding organization of the head,
there is less need for their conforming strictly to the
requirements of the passage, and they may, under
these circumstances, be dragged or pushed through
the pelvis, without any reference to the separate ca-
nals, until they reach the inferior strait. Here the
bis-acromial diameter will prove too long, under any
ordinary compression, to pass through the strait in
coincidence with the transverse diameter of the
strait, and the slioulders must rotate as they would
have if they had started right in the first place. It
will be to a great extent a matter of accident whether
they rotate so as to bring the right shoulder in ad-
vance, as it would have been after descent in the left
canal, or the left shoulder, as would occur after the
descent in the right canal.
But if the former occurs, the back of the child
being directed to the left side, the free head will
have its occiput turned towards the left, and in the
latter case, the child's back being to the right the oc-
ciput will also turn towards the right. It is not,
therefore, proper to say that observance of the direc-
tion in wliich the movement of restitution is made
will show us what the original position of the head
at the inlet must have been. Very generally the
shoulders observe the natural mechanism and the bis-
acromial diameter becomes coincident with the left
oblique diameter of the inlet with the right shoulder
58 HOW TO USE THE FORCEPS.
in advance. If the outline of the shoulders is not un-
duly large this relative position of shoulder and pel-
vic outline is maintained until complete delivery. A
l^lane passing transversely through the shoulders con-
tinues to be syn clitic with the successive planes of
the parturient passage until at the vulvar outlet it is
expelled. The right shoulder remains stationary at
the sub-pubic arch^ while the left shoulder sweeps
over the perineum. Where the shoulders are a little
larger than common, the plane just mentioned be-
comes oblique from the moulding of the shoulders, so
that the left or posterior shoulder is crowded in ad-
vance of the right shoulder and maintains this posi-
tion throughout, arriving at and passing through the
vulvar outlet before the right shoulder instead of
simultaneously escaping. Or it may happen that in
the moulding process the right or anterior shoulder
obtains precedence.
Opinions differ as to which of the two is the nat-
ural course, and probably from a want of sufficiently
numerous and accurate observations. Where it is
desirable to have exact knowledge, as when we at-
tempt to aid the process artificially, there are reasons
for preferring tlie prior delivery of the left or pos-
terior shoulder. Such an occasion often presents it-
self. The delivery of the head is frequently followed
by a more or less temporary cessation of uterine con-
tractions. Under such circumstances the child may
be in danger of asphyxia from pressure upon the
THE MECHANISM OF DELIVERY. 59
funis, if the body is large or the funis wrapped around
the neck, so that an immediate delivery of the shoul-
ders by the physician is to be recommended. If the
posterior shoulder is made to keep in advance, a
shorter diameter than the bis-acromial is permitted
to coincide with the antero-posterior diameter of the
tube, and a smaller outline being presented the peri-
neum is less distended. This is true whichever
shoulder is in advance, but the posterior is usually
more accessible to the finger and more easily drawn
down. Also, if the posterior shoulder is first deliv-
ered, the sharp projection of the shoulder is made to
pass over the perineum before the full bulk of the
body becomes engaged with it, and is therefore less
likely to make a rent in that structure, as so often
happens. The rest of the body follows the shoulders
at once, being too small as a rule to bear any definite
relation to the pelvis. Occasionally the breech is
large enough to fit quite closely when, being of simi-
lar outline to the shoulders, it observes the same
mechanism.
To recapitulate. The head in the first position
of the vertex enters the pelvis with its occipito-
frontal plane coincident with the initial plane of the
right canal, and therefore oblique to the plane of the
conjugate diameter. Its first movement is a com-
pound lateral and forward flexion, which brings the
plane of demi-flexion in coincidence, not with the ini-
tial plane of the right canal, but with a plane paral-
60 HOW TO USE THE FOKCEPS.
lei to that of tlie conjugate diameter, wliile at tlie
same time its outline is diminished. Its second
movement is rotation during descent, the former
bringing the occiput gradually in front while the
centre of the head moves spirally in the axis of the
right canal. At the inferior strait the flexion is, if
necessary, continued until, if not before, the plane
of complete flexion is made to coincide with the
plane of the outlet, the occipital end being directly
in front. This relative position continues while the
head undergoes a third movement, of extension, dur-
ing the rest of its course, being expelled from the
vulvar outlet in a state of complete extension, but
with the cervico-bregmatic diameter still at right
angles to the axis of the tube. Next the shoulders,
having engaged in the left canal, rotate as they de-
scend ; arrive at the inferior strait with the right
shoulder in front, which is detained under the pubes
until the posterior shoulder sweeps over the perineum,
and so out, when the rest of the child i")romptly
emerges. During the perineal stage the head movies
in a direction almost completely the reverse of its di-
rection at starting.
This mechanism maybe clinically verified in many
cases. At the outset of labor, when the os uteri is
but partially dilated, and the bag of waters uni-
formed, and the head resting loosely at the inlet, a
careful examination will show it to be situated as
follows : The posterior fontanelle will be almost in-
THE MECHANISM OF DELIVERY. 61
accessible, being at or above tlic ilio-pectineal line,
opposite a point in front of the left acetabulum.
The riglit branch of the lambdoidal suture will also
be ditiicult to reach, extending from the posterior
fontanelle in a direction nearly parallel to the top of
the 03 pubis, and ending in the small fontanelle at
the postero-inferior angle of the parietal bone. If
the head is still oblique this fontanelle can be felt,
and if the head is not unduly large even the ear may
also be detected in its neighl)orhood. But if the con-
tractions of the uterus have already forced the head
into a parallelism with the plane of the conjugate
diameter they will be entirely out of reach of an or-
dinary examination at this stage of the labor. The
sagittal suture will be felt extending first downwards
from the posterior fontanelle and then obliquely
backwards towards the right sacro-iliac symphysis,
thus having the same general trend as the long diam-
eter of the initial plane of the right canal. The
right parietal protuberance will be felt at or below
the level of the pectineal line opposite a point to the
right of the pubic spine and in a line which, verti-
cally drawn, would pass through the obturator fora-
men near its inner edge. So far as the finger can
determine, the central part of the presentation is mid-
way between the parietal protuberance and the sagit-
tal suture or thereabouts. And yet from the descrip-
tion it is evident that the centre of the presenting
part must lie in the sagittal suture and not to one
63 now TO USE THE FORCEPS.
side. This apparent discrepancy is due to the curva-
ture of the pelvis, so that the horizon of examina-
tion, as we may call the limit of the area within
reach of the fingers, difers from the horizon actually
present at the brim. The arguments as to the posi-
tion of the head, based upon the location of the caput
succedaneum which forms during the arrest of the
head at the inlet, are of doubtful value.
Carefully observed and recorded instances are
wanting, as is admitted by Matthews Duncan ; and,
until we have more exact facts, reasoning upon theo-
retical principles is fallacious. If I might venture a
hypothesis, it would be that the cajDut succedaneum
forms in front of the centre of the presentation for
reasons similar to those which cause the anterior lip
of the womb to become oedematous in preference to
any other part of the cervical rim.
As soon as synclitism takes place, the right branch
of the lambdoidal suture ascends above the os pubis,
becoming inaccessible until flexion and the descent of
the occiput bring it again within reach. This may
happen synchronously, in which case it does not
ascend, but in either case its direction will be changed
and it will no longer be parallel with the top of the
OS pubis. The posterior fontanelle becomes more and
more accessible with each degree of flexion. As rota-
tion and descent proceed it becomes more centrally
situated, being nearer the median line as well as lower
in the pelvis. The left branch of the lambdoidal suture
THE MECHANISM OF DELIVERY. 63
becomes apparent as soon as the head begins to rotate,
and even before, to some extent, when the head is
well flexed. The right parietal protuberance recedes
almost directly backwards and to the right side, and
when the head has reached the inferior strait each
protuberance maybe felt with some difficulty ex-
actly opposite to each other, while the posterior fon-
tanelle occupies the median line ; in the centre, if
the head is completely flexed, a little above or in
front, if flexion is less complete. At this time the
sagittal suture extends directly backwards, the two
branches of tlie lambdoidal suture extending from it
above like tlie arms of the letter Y. This adjust-
ment of parts to the pelvic tube is continued
throughout the remainder of the labor. The occipi-
tal protuberance, being in advance of the fontanelle,
appears first at the vulva, and as the latter orifice is
enlarged the rest of the i3resentation is gradually
uncovered until the parietal protuberances are exposed,
when the head slips out.
The compound flexion, rotation, and extension
are easilv observed and verified in the succession of
events, but the inward motion of the head is difficult
if not impossible to appreciate by direct observation.
The distance travelled is short, especially in front,
where our observation is mainly directed. The occi-
put also rotates in an opposite direction to the course
which the centre of the head travels, which further
obscures the problem. But although it cannot be
64 HOW TO USE THE FOUCEPS.
directly traced with the fingei% it is evident enough
from the conformation of the pelvis^ and receives far-
ther corroborative proof during the use of tlie for-
ceps.
Variations from this mechanism may and do occa-
sionally occur^ and are of some practical importance.
They may be said to consist in either an exaggeration
or deficiency of some of the natural processes. Thus,
a want of sufficient flexion at the inlet may cause a
long delay at the inferior strait, while this defect is
being remedied, or the head may fail to engage at all,
for the same reason. Flexion may be too great, or
rather extension may fail to occur at the proper
2^oint, causing delay in the perineal stage. A misap-
2')lication of the propulsive force may interfere with
rotation, or the head, being unusually small, may de-
scend obliquely throughout, and even be born in that
manner. Other variations arise from a disj)roportion
between the head and pelvis^ from a want of elastic
force in the perineum, or from other organic causes.
But where the head and pelvis are each normal and
l^roportionatc there is seldom any deviation from
the above-described process.
The time occupied in the movement of the head
through the pelvis varies in the same individual even,
from different circumstances. Normally, in multi-
para3, ten or fifteen minutes suffice, after full dilata-
tion of the OS, to complete the delivery of the child.
In primiparaj, from a half hour to an hour and a
THE MECHANISM OF DELIVERY. 65
half is usually rcquirecl;, ono half of which time is
consumed iii the perineal stage. Where the propul-
sive force is of ordinary strengLh these limits are
rarely exceeded, and if they should be in any case^
the cause for the delay should be carefully deter-
mined and if possible removed. The amount of de-
lay which should be regarded as demanding instru-
mental interference will be discussed in a subsequent
chapter.
2. The Second or Right Occipito-Anterior
Position (R. 0. A.) of the vertex is less frequent
than the flrst, for reasons already assigned, occurring
perhaps in ten per cent, of all positions of the vertex.
It is possible that it is frequently only a stage of the
third position, as will be mentioned under that head,
which was the view taken byNaegele in all cases. It
theoretically offers more difficulties and is more apt
to need assistance than the first position, from the
comparative smallness of the left canal and the en-
croachment of the rectum. So far as my own obser-
vations extend this is perceptibly true, but the dif-
ference is not great. It follows precisely the same
mechanism as the Qrst, with its direction of motion
reversed, and the description of the former mechan-
ism will answer as well for it, substituting through-
out the account "right" for or "left" wherever
needed. In this position the occipito-frontal plane
coincides with the initial plane of the left canal at the
beginning of labor. The head then descends in that
66 HOW TO USE THE FORCEPS.
canal, its centre following the axis of the left canal
until the point of fusion at the inferior strait is
reached, when it proceeds in the same conrse and
manner as the first does, during the remainder of its
course. Where there is any difference in the mech-
anism, it usually consists in a longer delay at the
inlet at the beginning until flexion is absolutely com-
plete. The shoulders descend in the right canal as a
rule, and are more apt to observe a uniform mechan-
ism than in the first position because they are nat-
urally placed in the more roomy canal. These two
occipito-anterior positions are the only ones in which
labor can strictly be called normal. The pelvis is
evidently constructed with a special design for such
a mechanism, and althouigh other ]oositions and
presentations have often an uncomplicated and easy
termination, they all have some elements which are
apt to give trouble and which show that they are ex-
ceptional.
3. In" the Third or Right Occipito-Posterior
Position of the Vertex (R. 0. P.) the head occu-
pies the right canal as in the first position, but with
its occipital end reversed. It is more frequent than
the second position, for some of the same reasons
which determine the prevalence of the first, and oc-
curs in about seventeen per cent, of all positions of
the vertex. At first siglit there appears to be no
reason why the same mechanism will not answer for
both anterior and posterior positions. If the calibre
THE MECHANISM OF DELIVERY. 67
of the tube is elliptical in outline it might be sup-
posed that the similarly elliptical outline of the head
might descend in ■whichever way the ends might
point, whether in front or behind.
For several reasons, however, the mechanism is
quite different. The principal cause of this is to be
found in the manner in which the head is joined to
the body, the point of attachment being towards the
occipital end, instead of in the centre of the head.
This causes the propulsive force, which is trans-
mitted through the vertebral column, to act in a line
too far back in the pelvis. The parietal protuber-
ances are also placed on the wrong side of the ilio-
sciatic line. To which wx may add that the occipital
end of the head is, if not larger, at least more firm and
resistant than the anterior. The effect of these con-
ditions will be best understood by observing the
course of the head.
Four methods of delivery are possible in this posi-
tion ; and yet, in spite of this variety, nature is often
incompetent to complete the task. The method
usually regarded as the most common one is as fol-
lows :
«, First, Meclianism. — At the beginning of labor
the head is placed wuth the occipital protuberance
opposite the right sacro-iliac symphysis ; the anterior
f ontanelle opposite a point in front of the left acetabu-
lum ; the left parietal protuberance is in front of the
beginning of the right ilio-ischiatic line, and in close
68 HOW TO USE THE FORCEPS.
relation with it ; the right protuberance is just to
the left of the sacral promontory. The occipito-
frontal plane is coincident with the initial plane of
the right canal, so that the head is obliquely placed
as in the first position, but in the contrary direction,
the left side of tlie head beino- lower than the ridit.
Tlie first effect of the uterine contraction is, as be-
fore, to remove this obliquity and bring the occiioito-
frontal plane into parallelism with the plane of the
conjugate diameter. Flexion is also coincidently in-
stituted, but with a modification of its effect. If the
occipital extremity of the head impinges closely
against the right sacro-sciatic arch, which is usually
the case, flexion has a tendency to bring the verte-
bral column of the child still farther backwards in
the pelvis and to wedge the head in the chord of the
arch — i.e., in the right sacro-cotyloid diameter (CD
in Fig. 20). The bi-j)arietal diameter is too large to
be so disposed of, and therefore the resistance of
the ends of the arch, viz., the promontory and an
opposite i:)oint in the right ileo-ioectineal line, throw
the head forward. Flexion has, in itself and apart
from the direction of the force, a tendency to throw
the bi-parietal diameter forward and nearer the cen-
tral line, and this operates also to make the head
clear the narrow sjoace in which its occii")ut would
otherwise be detained.
If a comparison is made between the outline of
the head and pelvis it becomes apparent that without
THE MECHANISM OF DELIVERY.
69
this forward movemGiit of the head there would be a
permanent arrest at this point, since the bi-parietal
diameter would lie, not in the left oblique diameter
as in the first position of the vertex, but in the chord
of the sacvO'Sciatic arch, which is always smaller than
this diameter. The disadvantage of having the pro-
pulsive force transmitted so far back in the pelvis is
therefore considerable. Flexion havino; continued
until this difficulty is obviated, the head descends in
the right canal with a spiral
rotation in the axis of that
canal, the occiput becoming
more and more posteriorly
situated, until it nears the
inferior strait. At this level
it encounters such an out-
line as is represented in
Pig. 18, in which A and B
mark the position of the ischial spines, and the
oblique line CD the bi-parietal diameter of the head.
The arrows show, the direction in which it is rotat-
ing. Now, at either end of this diameter are the
j)arietal protuberances, and to complete posterior
rotation and bring the occiput fairly in the sacral
concavity, the protuberances must ride over the
ischial spines or the ilio-ischial lines just above them.
This is not feasible if the proportions between the
head and pelvis arc at ail close. Therefore, the bi-
parietal diameter must beat a retreat and occupy the
Fig. 18.
70 HOW TO USE THE FORCEPS.
position it takes in the second position at this stage^
where^ from the fact that the ischial spines are back
of the central meridian of the pelvis^ only one of the
protuberances has to cross the ilio-ischial line, and
that not in a close relation. In other words, although
the canals are nearly identical here, there must be
a transfer of the head from the right to the left
canal.
Since an ellipse cannot be turned within its own
circumference, flexion must persist until the circular
outline of the cervico-bregmatic plane has been
reached, and then it is possible for the head to rotate
from the right to the left canal. In so doing, the
previous motion is simply reversed and rotation con-
Q tinned until the occiput is
brought in front and the
head placed precisely as in
j^—L ^ \ — j^ a right-occipito-anterior posi-
tion of the vertex after it
has reached the inferior strait.
This is accomplished mainly
by the action of the shoulders.
Fig. 19. The elliptical outline of the
shoulders was found to have its long diameter at right
angles with that of the head. If in Fig. 19 the long
diameter of the shoulders, AB, is placed over the bi-
parietal diameter, CD, where it actually falls, its ends
would project decidedly beyond C and D ; therefore,
in applying such an outline to that of the inlet, Fig.
THE MECHANISM OF DELIVERY. 71
20, the shoulders will be evidently seen to extend be-
yond the limits of the chord of the arch CD. And
if the bi-parietal diameter was too small to remain in
that relation, much more will the shoulders be de-
flected elsewhere.
In the great majority
of instances the shoul-
ders AviU be thrown to
the right of the verte-
bral column, since the
right shoulder will im-
pinge upon the verte- noTso
bral column just above a B, line in which the shoulders fail in
4. J? i-l anterior position,
the promontory OI the c D, line in which the shoulders fall in
,— ,, posterior position.
sacrum. ihey are
therefore forced to enter the right canal with the
back of the child antero-laterally placed instead of
entering the left canal, which at first sight appears
more natural. This brings the long diameter of the
shoulders parallel to the antero-posterior diameter of
the head while the latter is rotating posteriorly
about half way between the inlet and outlet, and the
neck is thereby twisted through an arc of 90°. This
involves tension of the neck, and therefore the devel-
opment of an untwisting force, which becomes con-
stantly greater, for as the head attempts to rotate
posteriorly, the shoulders being stationary at the brim
will cause it to be resisted, and as soon as the head
offers a circular and turnable outline, the untwisting
72 HOW TO USE THE FORCEPS.
force, added to the uterine efforts, accomplislies an-
terior rotation, and the head enters the inferior strait
with the occiput in front. It is probable that the
oblique direction in which the uterine force is trans-
mitted tends to promote rotation at all times. This
is at least worthy of investigation. A slight varia-
tion of this mechanism is occasionally observed in
which posterior rotation does not continue until so
low a level as the inferior strait, but flexion is either
completed at the brim or completed synchronously
with descent, anterior rotation also occurring grad-
ually throughout. By this commingling of the steps
the head is already rotated anteriorly or nearly so,
by the time the head arrives at the inferior strait.
1), TIlg second mechanism consists in anterior rota-
tion of the occiput at the inlet and an immediate
conversion into a second position (R. 0. A.), at that
point. It is generally believed that the first mechan-
ism is the most common, but, as already stated, Nae-
gele attributed all second positions of the vertex to
this second method. "With existing data it is impos-
sible either to prove or disprove the allegation, and
hence avc may properly classify the positions as when
we first see them, otherwise this would bo the most
frequent method of delivery in this position, tlie Ii.
0. A. being entirely discarded. Its occurrence is
favored by the large size of the head and a delay in
flexion. In such case, the disproportion will bo too
great to allow the occiput to descend at all while pos-
THE MECHANISM OF DELIVEHY. 73
teriorly pldced, and it is therefore forced anteriorly
in the only direction in which it can enter. The po-
sition of the shoulders has also much influence upon
it. If the child, in utero, is so placed that its back
looks to the risfht side of the mother, it is obviously
a matter of indifference whether the occiput is turn-
ed in front or behind ; but if the child's back is
turned directly forward the occiput must of necessity
come forward also, sooner or late]', if there is much
resistance at the be^'inninc: of its descent. The for-
ward turning of the body, when originally placed
nearly in the antero-posterior line, may be due to
the uterine contractions, volantary movements of
tlie foetus, or a cliangc of position of the woman,
which involves pressure of the abdominal muscles
upon the child through the uterine walls. It is tho
most favorable mechanism and the one to be brought
about artificially, if possible. After its accomplish-
ment the head proceeds as in the second position.
c, The third mechanism consists in continuous pos-
terior rotation, the occiput remaining posterior
throughout the whole delivery. Where there is a
great want of correspondence between the head and
pelvis, due to the smallness of the former or largeness
of the latter, tlic head may descend Avith the occij)ut
posteriorly or in any other way, like a shot in a mus-
ket-barrel. But in cases where a more exact propor-
tion exists, a definite and distinct mechanism is ob-
served. The head descends in the right canal as in
74 HOW TO USE THE FORCEPS.
the first mechanism, until it reaches the level of the
ischial spines when, instead of anterior rotation oc-
curring, the occiput rotates posteriorly. This is ef-
fected by great compression and moulding of the head,
so as to diminish the prominence of the parietal pro-
tuberances. If the shoulders are placed transversely
at or above the inlet, with the back squarely to the
mother's back, posterior rotation must occur or none
at all. The head is therefore arrested and moulded
by the propulsive force until its bi-parietal diameter
is sufficiently reduced. Usually complete flexion
first occurs with an abortive attempt at effecting the
first mechanism. When the ilio-sciatic lines or the
parietal protuberances are of average prominence
this is a tedious performance, consuming much time,
strength, and patience ; neither are the natural ef-
forts always adequate. When posterior rotation is
complete the head is placed in the outlet with the
cervico-bregmatic plane coincident with the plane of
the latter and the occiput directly posterior. The
disadvantages of the position accumulate as it at-
tempts to proceed. The manner in which the ver-
tebral column is attached to the head causes the pro-
pulsive force to be transmitted behind the centre of
the head and pelvis alike. The greater the flexion,
the nearer the foramen magnum is to the occipital
end of tlic head, and hence the line of force trans-
mitted by the vertebral column to the condyle on
cacli side of the foramen is thrown backwards by
THE MECHANISM OF DELIVERY. Y5
flexion. The head is therefore forced against the
end of the sacrum, or at best against the base of the
coccyx, and the secondary force originating in the pel-
vic floor cannot so well reach the head to impel it
forward. The uterine force must then be spent in
moulding the head until it is long enough to reach to
and be affected by the perineum. The occiput re-
maining stationary the head is cylindrically moulded
so that the cervico-bregmatic plane is thrown in ad-
vance of the outlet and a new plane made to take its
place, not by an extension of the head, but by its be-
ing compressed into a longer shape. After a time,
if the head is compressible, and the force holds out,
the head becomes long enough to be acted on by
the perineal force, and is then conducted to the vul-
var outlet and expelled. Where from the small size
of the head and body this moulding is unnecessary,
the cervico-bregmatic plane continues to occupy the
same position as in the case of the L. 0. A., but with
the occiput behind, and is so expelled, the forehead
gliding under the sub-pubic arch. The perineum is
in more danger of laceration from this mechanism
than from any other ; since the propulsive force is
directed so far back upon it, that it may be said to
attack it in the rear. The occiput is also more
pointed than the forehead, and more apt to make a
rent during its transit. This is, then, an unnatural
mechanism, even when spontaneous, and is to be pre-
vented if possible,
76 HOW TO USE THE FORCEPS.
dy A fourth termination exists, rarely witnessed,
but which may be taken advantage of in some cases to
the great benefit of the perineum. In tliis tlio mech-
anism is precisely tlio same as in the third method,
until the head is completely beyond the inferior
; strait, and resting on the perineum with the anterior
fontanelle within the lips of the vulva. At this
point anterior rotation may take place, the head ro-
tating around the axis of the cervico-bregmatic diam-
eter, from left to right, until the sub-occipital region
is brought under the symphysis pubis. It is then
an occipito-anterior position, and is expelled as such.
This was noticed to occur spontaneously by Cazeaux'*'
in one instance, and in another I have brought it
about by manipulation.! It likewise is probably due
to the influence of the neck and shoulders. If the
child's back is directed anteriorly, the untwisting
force of the neck may be resisted while the head is
in the bony pelvis, but whenever it has escaped from
it into a tube which is dilatable in more than one
direction, this force becomes irresistible, and whirls
the head around with the occiput in front. Even
when the shoulders descend with the back poste-
riorly, the untwisting force may be considerable after
jthey have advanced to any extent in the pelvis,
though rarely enough to effect anterior rotation.
* "Midwifery.*' Edition 186D, p. 267.
t ** American Journal of Medical Science,'* January, 1877.
THE MECHANISM OF DELIVERY. 77
Clinically, tlic third position of the vertex may be
observed as follows : At the beginning of labor the
anterior fontanelle, or its posterior edge, may bo felt
in front of the left acetabulum, or about in the same
position as the posterior fontanelle occupies in the
first position. It may usually, but not always, be
distinguished from the latter by its large size and
quadrilateral shape. The sagittal suture is found
extending diagonally to the right in the same fashion
as in the first position. There is also a suture ex-
tending from the anterior fontanelle corresponding
to the right branch of the lambdoidal suture, viz.,
the coronal, but it is more accessible at the begin-
ning of labor, though also nearly parallel to the top
of the OS pubis. The left parietal protuberance is to
be felt just in front of the right acetabulum, being
much further back than ihe light one is in the first
position. The bi-frontal suture is sometimes regard-
ed as a means of diagnosis in this position, since
Tvhen it is felt we may know that there are four su-
tures radiating from the fontanelle. It is scarcely
ever to be felt, however, and not at all unless the
head is abnormally extended, and the ear can, under
ordinary circumstances, bo felt with less difficulty.
The horizon of examination is similarly limited as in
the first position, the centre being at a point near
the anterior end of the left parietal bone, where the
caput succedaneum forms, if at all.
The most important distinction between the first
78 HOW TO USE THE FORCEPS.
and third positions as regards diagnosis is in the ef-
fects of flexion. In the first position the posterior
fontanelle becomes more and more accessible during
its progress and during rotation and descent, and
finally occupies a central position. In the third, the
anterior fontanelle, which has the same relative posi-
tion, is raised by flexion, and while at the inlet re-
cedes in direct proportion to its degree. If complete
flexion occurs, the anterior fontanelle entirely disap-
pears and the posterior fontanelle may be felt behind
and to the right of the centre of the horizon of exam-
ination. During descent the anterior fontanelle is
never centrally placed, even when in the median line
after complete posterior rotation. If the head is small
and flexion incomplete it may be felt in front during
the whole of the third mechanism, but otherwise if
the plane of complete flexion comes to be at right
angles to the axis of the canal, the anterior fonta-
nelle is not felt after the beginning of the labor until
birth.
4. The Fourth or Left Occtpito-Posterior
Position of the Vertex (L. 0. P.) bears the same
relation to the third that the second does to the first,
having the same mechanism in delivery, but with the
direction of motion reversed. It occurs in not more
than three per cent, of all positions of the vertex,
but the same possibility exists here as in the third,
that a few first positions were originally in the fourth,
and rotated at an early stage at far above the inlet.
THE MECHANISM OF DELIVERY. 79
For as the third is converted into the second by an-
terior rotation, so the fourth is converted into the
first by the same movements and under the same cir-
cumstances. Anterior rotation at the inlet is more
likely to occur in this than in the third position, on
account of the presence of the bowel to the left of
the sacral promontory. The smallness of the left
canal also favors anterior rotation, and therefore it
cannot be said to be more difficult than the third.
At the beginning of labor the occipi to-frontal
plane coincides with the initial plane of the left ca-
nal with the occiput behind, and w^ith a similar sub-
stitution of '^ right '' for '^ left/' the description of
the third position throughout will answer for this
one. «•
I think we may be justified in drawing the follow-
ing conclusions concerning occipito-posterior posi-
tions of the vertex.
First, they are not strictly natural positions.
Secondly, they have nevertheless definite mechanisms
of delivery which under favorable circumstances are
alone sufficient to secure their birth. Tliirdly, if the
head and pelvis are of average size, their spontaneous
delivery is attended with considerable delay in the
labor and may be altogether impracticable. Fourth-
ly, in a large proportion of cases the safety both of
the mother and child will be promoted by artificial
delivery. Fifthly, as the pelvic canals are of ellipti-
cal outline, the head cannot turn so as to be placed
80 HOW TO USE THE FORCEPS.
in an occipito-anterior position until it presents a cir*
cular piano wlioso diameter corresponds with the
shortest diameter of the pelvic canal. Flexion is
therefore the first requisite in all methods, whether
natural or artificial. Sixthly, to make anterior rota-
tion feasible, and with safety to the child, the shoul-
ders must present with the back anteriorly, or be so
rotated if they are not so originally. Seventhly, fail-
ing this, the forceps will greatly assist in the requi-
site compression, and also enable the physician to
control the passage of the head over the perineum
more effectually.
II. The Face Presentation". — In the facial
end of the cranium there is described a plane called
the trachelo-bregmatic, which is named after its
long diameter, which passes from the anterior border
of the anterior fontanelle to the front of the neck.
The transverse diameter of the plane, the bi-malar,
measures about three inches, the long, or trachelo-breg-
matic, about three and a half inches ; it is therefore
somewhat elliptical in outline. It is nearly parallel to
the cervico-bregmatic plane, but a little smaller in its
circumference. This is the plane which in this pre-
sentation corresponds in most particulars to the oc-
cipito-f rental in the vertical positions ; entering cither
canal, and in two ways, with the lower end or chin
in front or behind. The chin, then, or mentiim,
takes the place of the occiput in the nomenclature of
THE mecha:n'ism of delivery. 81
these positions, which arc as follows : 1, Left mento-
anterior ; 2, riglit mento-anterior ; 3, right mento-
posterior ; 4, leffc-mentO'posterior. This is also, as
near as may be, the order of their frequency, which i
is not great in any position, since the face is said to
present only once in two hundred and fifty or three
hundred labors. They are supposed to occur as the
result of displacement of the vertex, either from
wrongly directed force due to some mechanical diffi-
culty, or as the result of voluntary motion on the
part of the child. I have seen two cases in which a
shock to the mother a day or two before labor was at
least followed by a face presentation. In one, the
house in which the woman was, was struck by light-
ning two days before labor came on, and the sudden
start which one would naturally make under such
circumstances may very well account for the dis-
placement. In the other, a large picture fell from
the wall upon the mother's head, having, no doubt,
a similar effect.
1. Left Mento-Anterior Position". — If a head
is placed at the inlet in the third vertical or right
occipito-posterior position, and moved well back
under the right sacro-iliac arch, the parietal protu-
berances may be made to impinge upon the sacral pro-
montory behind and the ilio-pectineal line iu
front, while the occiput also rests upon the brim.
This, as before shown, is usually resisted by flexion.
But should the head nevertheless become impacted,
82 HOW TO USE THE FORCEPS.
the propulsive force acting tlirougli the vertebral col-
umn of the child can move only the long arm of the
lever, since the short one is wedged fast. Hence, ex-
tension will occur, and as it takes place the head
again becomes free. If the extension proceeds fur-
ther than is required to bring the occipito-frontal
plane below the level of the plane of the conjugate
diameter, the line of force is thrown in front of the
foramen magnum with increasing effect, and the ex-
tension is accelerated. This continues until the
trachelo-bregmatic plane takes the place of the oc-
cipito-frontal, with the chin in front of the left ace-
tabulum, and the anterior fontanelle opposite the
right sacro-iliac symphysis. This, however brought
about, constitutes the first position of the face pre-
sentation. The comparatively small size of the
trachelo-bregmatic plane makes it unimportant as
well as uncertain whether there is any lateral obliq-
uity or not. For the same reason we may say that
the face per se offers no difficulties in delivery, and
if the head was disconnected from the body it would
at once descend to the level of the cervico-bregmatic
plane ; after which the mechanism of delivery would,
be the same as in a vertical position. It is the man- .
ner in which the body and neck are made to enter
the pelvis that constitutes the chief obstacle in its
delivery.
If tlie head and pelvis are of average size, the
head descends in the right canal with its trachelo-
THE MECHANISM OF DELIVERY. 83
bregmatic plane coincident with tlie successive planes
of the pelvic cavity. But as it descends, and the
head approaches the inferior strait, the body, or
rather neck, is drawn into the pelvis. This brings
the length of the antero-posterior diameter of the
neck to be added to the depth of the cranium, or in
effect to the cervico-bregmatic diameter. This is
too much for the pelvis to accommodate, and the
head must be flexed to remove this difficulty. Flex-
ion would have to occur in any event, if the head is
to advance. But the line of force is througli a point
in advance of the centre of the head, and has no ten-
dency to bring about flexion. This can only be ac-
complished by the action of the secondary or peri-
neal force, and the head is too high up to be reached
by its influence. The further the unaltered head
moves under the propulsion of the uterine force, the
greater is the difficulty, since the occiput and neck
become more firmly impacted in the posterior part of
the pelvis. The only resource of nature is to mould
the head, by which process it becomes long enough
to reach where it can be pushed forward and flexed
by the perineal force. The neck is also liable to be
compressed and moulded, from w^hich great danger to
the child arises, for the neck is ill-adapted for such
pressure, and the circulation in the fcetal brain is
much interfered with. When the head is able to be
flexed the difficulty is mainly over, the mere act of
flexion causing the head to sweep over the perineum
84 HOW TO USE THE FORCEPS.
and to bring the face to the Yulvar outlet, nnless the
neck is unusually short. During descent the head
rotates, so that the chin appears in front and the
anterior fontanelle behind, but this rotation is not
due to any correspondence of the trachelo-bregmatic
l^lane to the pelvic canal. This plane is too small to
bring this about, but the cervico-bregmatic plane
which follows it is the one which regulates the mech-
anism. For this reason rotation is not as early in
the facial positions, not occurring until the head has
descended well in the pelvis, and the last named
plane become engaged. It is then regular and com-
jolete, the head emerging from the vulva with the
chin under the symphysis pubis. It escapes power-
fully flexed, and is immediately extended again, after
birth. AVhere the child is not large this mechanism
is almost as natural as the corresponding vertical po-
sition, the trachelo-bregmatic plane simply preced-
ing instead of following the cervico-bregmatic plane.
In fact, if the head alone were concerned, it would
be a more favorable position than the third vertical
position. But the implication of the neck and chest
make it a dangerous one for the child, and tedious
for the mother if delay is necessary to mould the
head.
Its clinical recognition is sufficiently easy at the
beginning of labor, but if it is delayed at any point,
and especially if it is detained at tlie inferior strait,
this may become a little difficult. The tissues of the
THE MECHANISM OF DELIVERY. 85
face allow of a caput succedaneum, or swelling, to
take place much more easily than the scalp, and the
face may be greatly puffed up and distorted from this
cause. Although as a general thing this swelling
subsides soon after labor, there is always a risk of ir-
reparable damage to the eyes, and lesser injuries.
Delay in delivery is therefore to be deprecated, and
should not be permitted to anything like the extent
which would be allowed in another presentation.
2. The Second, or Eight Mento-Anterior, is
similarly produced by the extension of a head origi-
nally in the fourth or left occipito-posterior position
of the vertex. It has precisely the same mechanism
as the first facial position, with the direction of mo-
tion reversed. It descends in the left canal, having
at the beginning of labor the chin in front of the
right acetabulum, and the anterior fontanelle oppo-
site the left sacro-iliac symphysis. It does not need
to be more particularly described.
3. The Third, or Eight Mekto-Posterior
Position, is produced by extension from the first
Yertical position. But it will at once be noticed that
it cannot be produced in precisely the same way as
a mento-anterior position. There is no chance for
the wedging of the bi-parietal diameter in front.
The extension of the head must, therefore, be attrib-
uted to other causes. Barnes's theory of too great
friction anteriorly may be tenable if coupled with an
anterior diversion of the uterine force, but after all
86 HOW TO USE THE FORCEPS.
there is nothing more probable than the cause as-
signed by Hodge, viz., the muscular movements of
the child itself. It is well that it is not easily
brought about, since it is especially difficult and dan-
gerous. In this position the trachelo-bregmatic
plane enters the right canal, as in the first facial po-
sition, but with its loug diameter reversed. The
chin is found opposite the right sacro-iliac symphysis,
and the anterior fontanelle in front of the left ace-
tabulum. Difficulties begin early. In all positions
the anterior part of the presentation moves less rap-
idly than the posterior, because of the curved con-
struction of the pelvic canals. Hence in this case
it happens that the forehead remains at the brim
while the chin and base of the cranium essay to ad-
vance along the posterior part of the pelvis. This tends
to bring the neck and chest at once into the pelvis,
and the obstruction begins at once. For this means
that a diameter of seven inches attempts to crowd into
one of five inches in length. The head would naturally
tend to rotate posteriorly with the chin to the rear,
until a new influence is felt in the descent of the
shoulders. In the mento-anterior positions the
shoulders follow in the opposite canal from that in
which the head descends, but in this, as in the occip-
ito-posterior positions, the shoulders are thrown
back over the right sacro-iliac arch. The shorter
the neck and the speedier the impact of the shoul-
ders the better, for the left or posterior shoulder is
THE MECHANISM OF DELIVEKY. 87
thrown to the right of the sacral promontory, and
the shoulders are thus brought over the entrance to
the right canal. This causes the chin to rotate an-
teriorly, and converts the position into a second or
right mento-anterior position, when it is finished, as
in that case. This anterior rotation may occur at
the inlet, but may also take place between it and the
inferior strait. It is closely analogous to the first
mechanism of the third vertical position, and is the
most favorable one in this position. If anterior ro-
tation does not occur, and the shoulders enter the left
canal with the back in front, the chin rotates into
the median line posteriorly and the head becomes in-
tensely extended. No relief is afforded even when
the head is permitted to reach the inferior strait,
since flexion cannot occur, nor could it assist if it did,
and extension has already reached its limit. The
further the body descends the tighter the wedging ;
and anterior rotation, the only resource, becomes
more and more difficult. Under any circumstances
there must be a great delay until the head is so mould-
ed as to be born in this fashion, and if it is at all
large this is impossible. The face will also be fear-
fully swollen and the head extremely ^' wire-drawn.'^
The necessity for aid, either manual or instrumental,
therefore, to promote rotation at an early stage, is
clear.
4. The Fourth, or Left Mento-Posterior Po-
sition, has the same mechanism as the third, with
88 HOW TO USE THE FORCEPS.
the direction of motion reversed^ and is therefore
sufficiently described in the above account, with due
substitution of '' right '' for '' left/'
The treatment of the facial positions will be con-
sidered incidentally in treating of the applicability
of the forceps to such cases.
PART II.
THE FOKCEPS.
INTRODUCTION.
" Sir,'* replied Dr. Slop, " it would astonish you to know
what improvements we lave made of late years in all branches
of obstetrical knowledge, but particularly in that one single
point of the safe and expeditious extraction of the foetus, which
has received such lights, that for my part (holding up his
hands) I declare I wonder how the world has — "
" I wish," quoth my uncle Toby, ** you had seen what pro-
digious armies wc had in Flanders.*' — Sterne.
" To procure easy travails of women, the intention is to bring
down the child, whereunto they say the load-stone helpeth ;
but the best help is to stay the coming down too fast. " — Bacon.
Whex Lord Bacon penned this sage remark^ the
forceps Tvere unknown, and in the light of other
days we are reminded of the fox and the grapes,
and similar instances of the depreciation of the unat-
tainable. For almost ever since their rude begin-
ning in the instrument of Chamberlen there have
been many who shared in the views of Dr. Slop, as
to the blessings of the forceps. When we think of
what the instrument can do, and of the numberless
lives which it has saved, it is difficult to avoid his en-
thusiasm, and vet it must be confessed that he was
aptly answered. For there is a debit as well as a
credit side, and it needs little research to learn that
the forceps have also been chargeable with much
harm, so that in many minds even now the balance
92 HOW TO USE THE FOKCEPS.
is doubtful concernins: tliem. That tlio fault is not
in tliG forceps, but in the users, it will bo my en-
deavor to show. They arc not simply a pair of
tongs, to be applied — somehow — to the child, and
pulled upon — somehow — until it is dragged out, but
a carefully adapted instrument, intended to be ap-
plied in a definite way and used in a definite man-
ner, accordins: to the case in which thev are used.
And when used with understanding, and under
proper conditions, they fully justify all the eulogy
which has ever been bestowed upon them.
The obstetric forceps are composed of two sepa-
rate and similar pieces of steel, each of which is fash-
ioned into a blade and handle. The pieces are made
to cross each other near tlieir middle, or at the junc-
tion of the blade and handle, at which point a de-
vice known as a lock is contrived so that compression
of the handle will cause an approximation of the
Fig. 21.— Davis Forceps (utper view). A, the blades;
B, the handles ; C, the lock.
blades. They are, as has been well said, a i')air of
steel hands, to be placed one on each side of the
child's head, to grasp it and draw it from the
mother. Like hands, too, they can grasp lightly or
forcibly. They are intended, primarily, to deliver
INTRODUCTION. 93
a living child from an uninjured mother. But they
can also be used to squeeze and drag down a dead
child, in the place of craniotomy. Whether this is
ever proper is another question.
Fig. £2.— Davis Forceps (side tie"^).
The first idea, then, of the forceps is of a tractor^
to be used to supplement or supplant the expuisivo
forces of tlie mother. To adapt them for farther
usefulness in conditions of disproportion between the
head and pelvis, tliey arc also made capable of com-
pressing the head so as to diminish its diameters,
and thus constitute a compressor, Thev mav also be
used to further the natural mechanism by flexing,
extending, and sometimes by rotating the head, and
in this sense may be regarded as a lever, but any use
of the forceps which implies a leverage upon the sides
of the obstetric canal, i.e., upon the mother's tis-
sues, is unscientific, dangerous, and criminal. A
properly constructed forceps will embrace these three
functions in one, the form of the instrument being
determined by these requirements. It would be in-
teresting to trace historically the successive changes
Y/hich have been made in the forceps during the two
hundred years of their employment, but as this would
94: HOW TO USE THE FORCEPS.
be of little practical value, it will be better to con-
sider only the ideal forceps as at present adapted.
For convenience we will consider first the blade,
which is the part in front of the handles, then the
handles, and lastly the lock.
1. The Blades. — The blades should be large
enough to cover a considerable part of the surface of
the head, so as to hold it securely, and with as little
pressure as possible on any one part. And since they
are frequently demanded, because of the tight fit of
the head in the pelvis, they must not take up any ad-
ditional room by adding to the diameter of the pre-
senting plane of the head. For these reasons the
blades should be wide, but with a large fenestrum,
through which the parietal protuberances of the head
project. In this way they will not add a fraction to
the size of the head. If the blades are narrow they
will not exert so equable a pressure upon the head.
Also in this case the fenestrum will be correspond-
ingly small, and the convexity of the head cannot so
well protrude between the branches of the blade ; the
diameter is therefore liable to be increased by such an
instrument. A good, wide blade, with a correspond-
ingly wide fenestrum, is the first requisite in the
forceps. It is alleged by some that a wide blade is
more difficult to introduce than a narrow one —
which is in a measure true, but since the wide blade
can always be readily introduced in any case which is
suitable for the application of the instrument, it is of
INTRODUCTION. 95
no consequence that another blade can be more read-
ily used. A blade only a finger-breadth wide could
be introduced still more easily, but would be of no
use. A width of two to two and one-eighth inches
will be sufficient, with a fenestrum one and one-half
inches in breadth.
a, Head Curve. — When a pair of scissors, for in-
stance, is opened, the points widely diverge, so that
an instrument made in this way with straight blades
would have a very slight grasping power. In fact,
the only hold which such blades would have upon an
object would be such as powerful lateral pressure
would give. This in the forceps would be a great ob-
jection, since the object to be grasped is the more or
less compressible head of a living child, and such pres-
sure is liable to injuriously affect the intra-cranial
circulation, if not the integrity of the brain itself.
Compression of the head is at times desirable and
necessary, but in many, if not most, instances, all
that is required of the instrument is that it shall hold
the head securely with a minimum of compression.
For this reason the blades are bowed outwardly to con-
form to the curvature of the head. This is known
as the liead'Citrve of the forceps. It must not be so
slight that the head will readily slip from between the
blades, nor must it be very great, else there would be
great difficulty in applying them. With a proper
head-curve the tips of the blades will approximate to
such an extent, when the instrument is applied, that
96 HOW TO USE THE FORCEPS.
traction upon tlie blades brings their distal end upon
tlie farther end of the head, so as to not only secure-
ly hold it, but also to push it onwards. When for-
ceps are said to slip during their use, one of two
things is certain ; either the head-curve of the in-
strument is insufficient, or the blades have not been
properly applied. In the Davis forcejos the tips of
the blades are one-half inch apart when the instru-
ment is closed, and when open sufficiently to hold a
head measuring four and a half inches in the bi-
parietal, the tips are two and three-quarter inches
apart. It is obvious that if the head is really in the
blades of this instrument, they cannot slip unless the
steel blades are so thin as to allow of their being
sprung outwardly at the tips. This latter is an ac-
cident which I think does occasionally happen in
some forceps, but is guarded against in the Davis
forceps by a secondary head curve in the blades,
namely, a curving from above downwards. This
twisting of the blades makes them much stronger, for
the outward acting force of the child's head is ap-
plied almost edgewise to the arms of the blades,
instead of throuQ,-li their thinnest diameter. This
secondary curve also adapts the instrument more ex-
actly to the convexity of the head. The forceps arc
also iield upon the head by the pressure upon them
of the soft parts and pelvic walls, and in cases where
there is not a tight fil; and the forceps are applied
merely for lack of uterine contractions, an instra-
INTRODUCTION. 97
ment with no head-curve at all may be sufficient to
withdraw the head. In difficult cases the head-curve
is absolutely necessary, and in any event, the instru-
ment which is useful only in the cases where it is
least needed is not a desirable one.
5, Pelvic Curve. — The curvature of the pelvic
tube in its whole length is considerable. As before
shown, the child in escaping from the vulvar outlet
takes a direction almost exactly opposite to that in
which it enters the pelvis. Much of this curvature
is indeed in the soft parts, and therefore both varia-
ble and capable of being overcome by a straightening
pressure against the walls. It is true that a pair of
forceps which are nearly straight quoad their length
can be made to seize the head when quite high up in
the pelvis and even at the inlet, but it is much more
convenient to have the instrument conform to the
curvature of the pelvis. This is known as the pelvic
curve, and is surprisingly different in different in-
struments, varying from a. barely perceptible curve to
one in which the ends of the blades are nearly at
right angles to the rest of the instrument. The
curvature of the male catheter, for instance, is com-
paratively uniform, and there is no reason why so
great a diversity should exist in the forceps in this
respect. The pelvic curve of the Davis forceps, which
is greater than that of most instruments, seems to me
to be most suitable. It not only enables us to apply
the blades to the head at any point with great facil-
98 HOW TO USE THE FORCEPS.
ity, but it allows them to be adapted to the head in
a superior manner. The blades, by reason of this
curve, will be more nearly parallel to the axis of the
presenting plane of the child's head than if the
blades were straighter, and it will therefore be easier
to make the traction in the proper direction.
There are, then, two valid reasons for a consider-
able pelvic curve ; first, that it allows of greater ease
in application, and second, that the blades will be
applied to the head in a more desirable way. Such
an instrument can be used at any point, the straight
forceps only when the head is at the inferior strait,
without great pressure upon the perineum, and con-
sequent discomfort to the mother. The exact man-
ner of curvature, whether it shall be gradual from
the lock to the tip, or whether it shall begin at some
distance in front of the lock, is a matter of some mo-
ment..
In the Davis forceps (Fig. 21), tlie shanks of the
blades are continued in front of the lock, straight,
parallel, and close together, for an inch and a half
before either the pelvic or head-curve begins. This
insures that the lock shall bo outside of the vulva in
most cases, even when they are used at the inlet.
In many instruments, both curves begin at the lock,
which seems to me to be a disadvantage, since the
blades are relatively shorter and are unnecessarily
wide in the immediate neighborhood of the lock.
Tlie pelvic curve of tlie Davis forceps is peculiar, be-
INTRODUCTION. 99
ing increased by widening the fenestrum posteriorly,
or rather by having the two bars of the blade nearly
parallel, and making the curvature principally in the
lower bar. This gives them an exceptionally grace-
ful appearance, which can be appreciated better by
direct inspection of the instrument than by any de-
scription.
The blades are by these curves fully adapted for
seizing and securely holding the head, but they must
have handles to facilitate their introduction and to
assist in traction, while to admit of compression they
are made to cross each other at the look.
2. The Handles. — The handles are continuous
with the blades, and are made of even more diverse pat-
terns than the latter. Some are made of great length,
in order to increase the leverage power of the instru-
ment. Some are provided with rings or shoulders, to
enable more powerful traction to be made with them.
Some are provided with a blunt hook at the extrem-
ity, for the same purpose, and for convenience of
having a double instrument. Some are made in
pieces, so that the handles can be made either long
or short. I again select the Davis forceps as possess-
ing the most desirable handles. They are not bulky, \
are straight and uncomplicated, are long enough to
allow of being comfortably grasped by one hand, or
even by two, if that were ever necessary. Their
length is between four and five inches behind the
lock, which is enough. In speaking of traction dur-
100 now TO USE THE FORCEPS.
ing the use of the forceps, 1 will explain why I do
not regard the handles as the important agent in pro-
ducing traction, and also show that the length above
mentioned is sufficient for the proper use of the lev-
erage power of the instrument. If I am correct in
stating that such handles are sufficient for all practi-
cal purposes, their advantage over other forms is ob-
vious. They are small and convenient, and there is
nothing about them to get out of order or in the
way. The rings and shoulders and blunt hooks are
in the way during introduction, and have the ad-
ditional disadvantage of inviting us to make trac-
tion in the wrong direction. In some forceps the
handles are entirely of steel, and are usually so small
that a firm grasp becomes painful to the operator.
It is better to affix to them pieces of wood or hard
rubber. It is hardly necessary to add that both the
blades and handles should have all sharp edges re-
moved, and. carefully rounded so as to avoid injury
to the tender structures about which they are used.
3. The Lock. — The lock is by no means the least
important part of the forceps. There are three
forms of lock in common use : the English, or mor-
tise-lock, the screw and slot-lock, with which the
Hodge forceps is usually provided, and the flat but-
ton-lock. Tlie first is the most objectionable. In
the first place, the danger of pinching the maternal
tissues when the lock is close to the vulva is greater
than in any other. Secondly, the forceps may be
rSTRODUCTION. 101
locked when the blades are not in exact apposition,
but when one blade is introduced a little further
than the other. But as soon as traction is made the
blades will slide into their proper relation, in which
case the blade which has been in advance will usual-
ly injuriously scrape the child's head and either
bruise or lacerate it. This can be avoided if suffi-
cient care is taken, but it is better to have a lock
which utterly prevents it. Thirdly, tlie blades fitted
with this lock cannot at a glance be distinguished
one from the other, but must be fitted together be-
fore we can tell which is the right and which the
left blade. This may appear to be a trivial matter,
but any one who has used all kinds will appreciate it.
In the second form of the lock one blade is provided
with a slot, and the other with a pivot which termi-
nates in a large upright screw-liead. When the
blades are opposite each other, upon the head, the
pivot is just opposite the slot, and may be pushed
into it. The screw-head is then rotated between the
thumb and finger until the lock is made fast.
Tliere are two objections to this form. First, the
looseness of the lock allows of the pivot being inserted
into the slot when the blades are introduced to an
equal length, but before they are exactly opposite,
and when they are somewhat tilted. Then, when the
screw is tightened, they may be forced into exactness.
Secondly, the projecting screw-head is often in the
wav, and when the lock is close to the vulva cannot
102 HOW TO USE THE FORCEPS.
be turned with ease. These objections can be mainly
overcome by screwing down the pivot so as to make
a close fit before beginning to introduce the blades,
but there still remains the fact that the projection is
too great for convenience. In the third form one
blade is provided with a slot and the other with a
closely-fitting pivot which is capi^ed by a flat button-
like expansion. When the blades are in exact oppo-
sition the slotted blade glides under the button and
the instrument is locked, but unless the instrument
is exactly adjusted this cannot be done. We have,
then, in this lock a safeguard against a faulty appli-
cation, and when the instrument is locked a guaran-
tee that they are properly applied. The pivot is so
low as not to be in the way, and the two blades can at
once be distinguished from each other. With the
last two locks, the slotted blade is known as the fe-
male blade, the one with the pivot, the male blade.
Otherwise the blades are distinguished as right and
left, according to the side of the pelvis to which they
are applied, and sometimes anterior and posterior or
upper and lower, which are variable terms, for one
blade may be in either position according to the case
in which they are used. So far as nomenclature is
concerned the slot and pivot lock, then, is much more
convenient. I will not undertake the invidious task
of pointing out the imperfections of the various for-
ceps now in use ; ])ut will simply state my belief,
founded on the principles above stated, tliat the Da-
THE APPLICATION OF THE FORCEPS. 103
vis forceps provided with the button-lock, as made
by J. H. Gemrig, of Philadelphia, from a reliable
mode], is the best instrument for general use. It is
the instrument used by the accomplished Professor
Charles D. Meigs, who declared that it was as near
perfection as could be attained, and did not attempt
to modify it, and has been used for many years by
such veteran obstetricians as Ellwood Wilson and
Albert H. Smith, of Philadelphia. Care should be
taken in procuring the instrument, for those made
by several manufacturers are not correctly made, and
leave out some of its most important characteristics.
Such forceps as have special forms or modifica-
tions for a particular 2^i^rp^^G ^^J t>e briefly noticed
in treating of the use of the instrument. There is
no doubt that special skill in the use of any double-
curved forceps may enable an operator to use it effect-
ively ; the same amount of skill devoted to the Da-
vis forceps will bring a better return. I say noth-
ing of the straight forceps, because it is nearly obso-
lete, and every text-book bears witness against it ;
nor of forceps for use upon the breech, as this appli-
cation of the instrument is not yet well established.
THE APPLICATION OF THE FORCEPS.
The forceps, being specially designed and adapted
for the head, may be applied to it in any of its pre-
sentations and positions, and at any point in its
course. The indications for their application will be
104 HOW TO USE THE FORCEPS.
discussed in another place, so that we will assume a
suitable and uncomplicated case, in which the os
uteri is fully dilated. Although the head may be ar-
rested in any part of the pelvis, we are practically
seldom called upon to apply the forceps except in
two situations, viz., when the head is at the inlet or
at the outlet of the j)elvis. It is also necessary at
times when the head is resting upon the perineum
and in great measure through the outlet, but as the
tube is single from the outlet onwards, there is no
difference in the aj)plication of the instrument. At
the inlet the conditions are decidedly different, and
the method of using the forceps is likewise different.
I. We will consider, first, the application when the
head is at the inlet and in the first vertical position
(L. 0. A.) in a pelvis which is of normal propor-
tions. .Certain preliminaries are requisite. First,
the forceps are to be taken from their bag, or case,
and placed in a basin of warm water, so that they
shall be of the proper temjoerature. Care should be
taken that the blades are not rattled against each
other while handling them, as the clang of steel is a
peculiarly disagreeable sound to those who are about
to be *^ operated upon." Next, the woman should
be placed in a proper position : lying upon her back,
transversely in the bed, witli the hips brought to the
edge, so tliat the vulva ovcrliangs tlie edge and with
the feet placed upon two chairs. One, or better two,
sheets may l)e placed over the limbs, so as to avoid
THE APPLICATION OF THE FORCEPS. 105
any exposure, but the yulva should be uncovered so
that the operator shall see exactly what he is about.
Right-minded persons will offer no objections to any
necessary procedure, and it is better to wound the
feelings than the pelvic tissues by uncertain manipu-
lations under the bed-clothes which are certain to get
in the way. The English prefer to apply the forceps
with the woman upon her side, which is much more
diflScult and sometimes well-nigh impossible. As we
can never be sure beforehand of the amount of diffi-
culty we shall encounter, it is best to secure the most
favorable position at the start. A third chair should
then be placed between the others, upon which the
operator is to sit, and the forceps are to be placed
within reach. A supply of lard and several towels
complete the equipment. If there is any doubt as to
the condition of the bladder, a catheter may be pass-
ed, but this is sometimes impracticable. I assume
that the rectum has been emptied by an enema.
Where are the blades to be applied in the first po-
sition at the inlet ? There are several reasons for the
unhesitating answer, on the sides of the child's head.
First, they will fit the head better. Secondly y they
will be less likely to injure the head when com-
pressed than when in any other situation. Thirdly,
they will be applied in a very definite relation to the
head, so that when we move them in any direction we
know exactly in what way the presenting plane of
the head will be disturbed. Fourthly , we can, if
106 HOW TO USE THE FORCEPS.
necessary, flex or extend the head, or otherwise con-
trol its relations much better when the head is
grasped in this fashion. In fact, flexion of the head
is next to impossible when the forceps are otherwise
applied. FiftJily, the head can be reduced in size
more certainly than in any other way, since the ap-
proximation of the blades compresses and reduces the
bi-parietal diameter, while forced flexion of the head
can be made to reduce the antero-posterior diameter,
by substituting the cervico-bregmaticforthe occipito-
frontal. And lastly, the application is no more diffi-
cult than any other in the un deformed pelvis. The
head, in the position under consideration, is quite
closely applied to the pelvic brim ujDon the right side
of the pelvis and upon the left side in front. One
part of the head is at some distance from the brim,
viz., th'e left parietal region, which is opposite the
left sacro-iliac arch. One blade of the forceps then
can very easily be placed just where we want it, on
the left side of the head, since there is a roomy pas-
sage for the blade. The blade which is to be oppo-
site this one must be insinuated between the right
side pf the head and the pelvic rim to which it is
closely adjusted. But what is true of this latter
blade is true of both in any other method of api)lica-
tion. It is only when the blades are applied to the
sides of the head that even one of them has a place
provided for it, as it were.
The next consideration of importance is, wliich
THE APPLICATION OF THE FORCEPS. 107
blade should be first applied ? In answering this we
will notice that one side of the head is j)osterior and
remote^ namely, the left side ; the other is anterior
and near. The fact that one side is more posteriorly
placed than the other will decide the question
for us, for if the anterior blade was first passed it
would be in the way during the application of the
second. These questions being settled, the oper-
ator sits in front of the vulva, takes up the male
blade of the forceps, and thoroughly anoints the part
to be introduced and also his right hand. The lat-
ter is to be introduced into the vagina as far as the
thumb, or until the finger-tips can be placed between
the OS uteri and the head. Sometimes the introduc-
tion of two fingers will be sufficient for this purpose.
If so, all the better, but this precaution should never
be omitted, lest the blade should pass to the outside
of the cervix, when even a slight amount of force
ma}'' result in great damage to the maternal tissues.
The handle of the forceps should be securely grasped
in the left hand ; not held like a pen, which for an
object of its weight gives an insecure hold, but held
firmly so that it can be introduced with precision.
A firm hold does not imply a forcible use, but on the
contrary, the ability to grade force with entire deli-
cacy. Tlie tip of the blade is then inserted in the
vulva resting against the palm or surface of the fin-
gers, while the tip of the handle is held perpendicu-
larly above the middle of the mother's right groin.
108 HOW TO USE THE FORCEPS.
Since this blade is to traverse nearly the whole pos-
terior curvature of the pelvis before coming in con-
tact with the head, the pelvic curve of the instrument
* is to be first considered, and it is to be passed almost
exactly as we would pass a male catheter into the
male bladder. As the blade glides upwards, the tip
of the handle moves almost directly forward, and with
little depression until the blade has reached the lower
limit of the side of the head. The head curve of the
forceps must now be considered, and the blade made
to pass around the convexity of the head. As this
movement is executed the handle of the forceps is
made to approach and cross the median line, and at
the same time is rapidly depressed. As the blade
continues to be moved onward in the line of its pel-
vic curve to a certain extent, the motion is somewhat
spiral ; but the greater part of the motion in this di-
rection is effected during the first movement ; hence,
during the second, the line of motion of the tip of
the handle is almost straightly diagonal from above
downwards. When the introduction is complete the
blade is in the free space under the left sacro-iliac
arch, and applied to the left side of the child's head.
The handle will rest against the perineum and will
have its face turned somewhat to the left thigh of the
mother, its direction being nearly in the axis of the
initial plane of the right canal. As soon as the tip of
the blade is felt to be between the cervix uteri and the
head, the hand or fingers may be withdrawn from the
THE APPLICATION OF THE FORCEPS. 109
vagina. The introduction of the male blade is al-
most without exception very easy. If properly direct-
ed to its destination it slips into place almost from
its own weight. The second blade does not enter
quite so readily, but, under ordinary circumstances,
its introduction is not difficult. The right hand is
freed from its inunction with a towel and takes up
the female blade, which with the left hand is then
anointed as in the case of the preceding blade. The
right side of the head is much nearer than the left.
It will therefore usually suffice to introduce two
fingers of the left hand as a guide and safeguard be-
fore passing this blade. From the proximity of the
right side of the head, the head-curve of the blade
has to be considered almost synchronously with the
pelvic curve. For almost as soon as the blade begins
to be introduced it must be curved around the head.
It is therefore held nearly at right angles to the me-
dian line, with the handle in the line of the mother's
left groin, while the tip of the blade is inserted in
the vagina, resting against the palmar surface of the
fingers. The part to which we desire to apply the
blade is almost directly over the right obturator fora-
men. The handle is therefore at once moved towards
the median line, and depressed as soon as it is clear
of the mother's left leg, while it is pushed onward at
the same time, so that the line of movement is con-
tinuously spiral. I have said that the head was
closely applied to the rim of the pelvis on the whole
110 HOW TO USE THE FORCEPS.
of the right side of the latter ; but if the head is well
flexed the frontal end will not entirely fill up the right
sacro-iliac arch. Hence there is a tendency in this
blade to slip posteriorly into this opening. If it
does the blades will not be opposite, but their con-
cavities will both look forward and they will not grasp
the head and cannot be locked. To avert this we
keep the blade well forward during its introduction,
and this can be promoted by a simple manoeuvre.
One finger of the left hand is retained in the vagina
and placed under the upper bar of the blade. With
this we can push the blade upwards while the right
hand is urging it onward. The amount of force re-
quisite for the application of the second blade is usu-
ally greater than that demanded by the first. Wiiere
the forceps are applied only on account of uterine in-
ertia, rather than for any detention from dispropor-
tion, or where the head is resting above the inlet
rather than engaged in it, there is not a great differ-
ence. The amount of force which is justifiable can-
not, of course, be measured, but when the operator
is thoroughly aware of the true relations of the head
to the pelvis, it is never very great. When the sec-
ond blade is thoroughly introduced its liandle crosses
that of the first and the slot comes just ojiposite the
pivot and a slight compression of the handles locks
the instrument. If the parts of the lock do not en-
tirely and easily coincide, we must withdraw the sec-
ond blade and apply it with more care until it can
THE APPLICATION OF THE FORCEPS. Ill
be brought in proper relation with the first. When
this is accomplished without difficulty, we may be
certain that the head is grasped in its bi-parietal di-
ameter, and may proceed to its extraction in the full
confidence that we know exactly what has been
done. The position of the handles when the forceps
are thus applied is instructive. The head being
grasped in its bi-joarietal diameter, the face of the
handles is directed towards the left side.
But we may notice also that the handles are not in
the median line, but point decidedly to the left of it.
And the higher the position of the head the greater
the divergence of the handles from the median line.
If the head was centrally placed in the inlet, as stated
by Pledge, this would not be the case. But its cen-
tre is decidedly to the right of the median line as
we have already stated, and therefore the handles
occupy this position, which is a clinical proof of the
truth of the views herein entertained of the mechan-
ism of labor. The practical bearing of this will be
discussed under the head of traction.
It sometimes happens that when both blades have
been apparently correctly introduced, the parts of the
lock are still too far apart to be united. This is often
due to the fact that they have not been introduced
far enough. In this case the handles maybe taken
one in each hand and pressed avcU against the peri-
neum, when they will usually lock. When the head is
above the brim this is always necessary, and when
112 HOW TO USE THE FORCEPS.
fairly engaged in the inlet the handles are quite close
to the perineum when fully applied. Care should be
taken in locking the blades not to pinch the vulvar
tissues or allow hairs to be entangled in the lock.
The application of the forceps to the sides of the
head when at the superior strait — is taught by
Dewees, Meigs, and Hodge, and by a small minority
of English and continental authors. Even these ad-
mit exceptions, and state that the blades cannot al-
ways be thus applied, and Dr. Davis himself was
sometimes unable to introduce the second blade of
his forceps upon the right side of the head. Nearly
all, however, admit the advantages of this method,
and merely allege its difficulty. In place of it many
recommend that the blades shall be passed with refer-
ence to the pelvis, one upon each side, in which case
the head will be grasped obliquely. The disadvan-
tages of this jirocedure are mentioned by implication
in the enumeration of the advantages of the method
already described.
There is a much greater risk of injuring the head,
in addition to the less perfect control which is ob-
tained of its movements. I believe that the objec-
tion to the cephalic application of the blades is un-
warranted and founded upon several erroneous con-
clusions.
First, there is not a sufficient discrimination
made between the application of the forceps in nor-
mal and deformed pelves. It is probable that in
THE APPLICATIOISr OF THE FORCEPS. 113
some cases of pelvic deformity the blades cannot be
applied to the sides of the head. But I utterly deny
even the difficulty of application in the normal pel-
vis, except when from the extreme size of the head
no method is adequate, as in hydrocephalus. This
is an important point, since the rule should not be
conformed to the cases of deformed pelves, which
are comparatively rare, but to those in which the pel-
vis is normal, which are much more frequent.
Leishmann says explicitly : " Delivery by the long
forceps may practically be considered as an operation
in w^hich the head is arrested by reason of contrac-
tion of the pelvic brim" (Syst. p. 4GG). Secondly,
there is not enough difference made in the manner
of introducing the blades. The English have indeed
hardly given in their adhesion to the use of the
long, double-curved forceps, having shown a tend-
ency to protract the infancy of the instrument in a
characteristic way. Thirdly, there is not enough
difference made in the manner of introducing the
second blade, and it is improperly introduced. The
teaching of Baudelocque, Levret, and Cazeaux is
substantially the same as that of Leishmann, which is :
'' This blade may also be passed in the direction of the
hollow of the sacrum." Schroeder, p. 1?7, is more
explicit. " Ho takes the right blade in the right
hand, . . . and proceeds in the same way as just de-
scribed. Both blades are now situated somewhat be-
hind, and in order to lock the forceps, either both or
Hi HOW TO USE THE FORCEPS.
at least one of the blades must bo brought forward ;
in the first head position the right-hand blade. '^ In
other words, one blade is to be jiassed under the left,
the other under tlie right sacro-iliac arch, after
which either the right blade is to be brought for-
ward and opposite the other, or both are to be
brought to the sides of the pelvis until they are op-
posite. It is no wonder that with such directions
the application is difficult. Barnes, p. 59, says :
'' The instrument held in the right hand lies nearly
parallel with the mother's left thigh, or crossing it
with only a slight angle. The point of the blade is
slipped along the j)almar aspect of the fingers in the
vagina, across the shank of the first? blade i7i situ,
inside the perineum toward the hollow of the. sacrum.
As the point has to describe a helicine curve to get
round the head-globe, and forward in the direction
of Carus's curve, the handle is now depressed and car-
ried backward until the blade lies in the right ili-
um.^' I do not wonder at his abandoning the at-
tempt to apply the forceps to the sides of the head,
if the second blade is passed in this fashion. But if
it is held at first, not parallel with the mother's
thigh, but at right angles with it, the blade may be-
gin to curve around the head very soon after it en-
ters the vagina, and can be kept in front w^ith little
difficulty. And so far from it being proper to pass the
second bladq under the right sacro-iliac arch, and
then bring it forward, if we are so unfortunate as to
THE APPLICATION OF THE FORCEPS. 115
get it in this position, it should at once be withdrawn
and the attempt be renewed to pass it properly. One
reason Avhich is given by Barnes, Fauntleroy, and
others, for the pelvic application of the blades is
that it dispenses with the need for our knowing the
position of the head when using the forceps. But
after they are on, it is of great importance that we
should know in which canal the head is situated, and
whether our efforts are or are not flexing or extending
the head, which cannot be done unless we know the
position of the head. To apply the forceps in a haphaz-
ard way to the head is a very unscientific procedure,
and is not safe even for experts with the forceps, much
less for the unskilled and careless, to whom the doc-
trine that we need not know the position of the head
comes with peculiar comfort. There are occasionally
met with cases in which the determination of the po-
sition is extremely difficult, but to make these the
basis of a rule is not an indication of progress in our
science.
The rules here given for the application of the
forceps to the first position of the vertex at the inlet
apply equally well to the third vertical and to the
first and third facial positions. In other words,
whenever the head is in the right canal, the forceps
are to be thus aj^plied. As this embraces the great
majority of cases in which they are used, the doc-
trine of chances would lead us to apply them in this
way whenever we were uncertain as to the position of
116 HOW TO USE THE FORCEPS.
the head. Any uncertainty, however, can usually
be cleared up when the hand is introduced as a pre-
liminary to passing the first blade.
When the head is in the second or fourth positions,
or in the left canal, the order of applying the blades is
reversed. The female blade is first to be introduced
and passed under the right sacro-iliac arch. The male
blade is then introduced upon the left side and in front
in a similar manner to the introduction of the second
blade in the first position. But when this is done the
forceps cannot at once be locked, since the blade with
the pivot will come on top of the blade with the slot.
We therefore take hold of each handle, press them
well back towards the perineum, and at the same
time slip the handle of the female blade over and across
the male blade, when the parts of the lock will be in
proper relation to one another. This is a slight incon-
venience, but by no means as great as that attending
the reverse method of introducing the blade, in which
case the anterior blade will be decidedly in the way
while introducing the posterior one. The manoeuvre
should be performed with care and gentleness, re-
membering that the points of the blades are within
the uterus, and are partaking of the motion commu-
nicated to the handles. When the forceps are ap-
plied upon a liead in the left canal, the handles will
be observed to extend nearly in the axis of the initial
plane of that canal, being to the right of the median
line and with their face directed to the right.
fHE APPLICATION OF THE FORCEPS. 117
IL At the outlet. It is occasionally necessary to ap-
ply the forceps while the head is between the inlet and
outlet of the pelvis, and therefore imperfectly rotated.
The application is made in substantially the same
way to the sides of the child's head. Such cases are
comparatively infrequent. If the head passes the in-
let it is rarely detained until it reaches the inferior
strait, and has accomplished its rotation. At this
point, or when resting upon the perineum, the for-
ceps are most frequently needed. As the sides of the
head correspond to the sides of the pelvis, the long
diameter of the head being in the median line, the
blades will be applied to the opposite sides of the pel-
vis, in the following- manner : Two fingers of the
right hand being introduced as a guide, the male
blade is taken in the left hand and held at right an-
gles to the median line, with the tip of the blade in
the vulva. As soon as the blade reaches the left side
of the head the handle is moved spirally downwards,
backward, and onward, while the blade curves around
the head and onwards into the pelvis. The same
procedure with changed hands is repeated with the
female blade, when the handle will be found in the
median line, but not pressed against the perineum as
when the application is made at the inlet. But no
matter where the head is, if it has not completely ro-
tated, the application should be made to the side of
the head, which cannot be denied to be perfectly fea-
sible at the outlet, whatever may be thought of the
higher operation.
118 HOW TO USE THE FORCEPS.
III. The forceps are sometimes applied upon the
after-coming head, after the delivery of the body and
arms of the child. The method is the same as when
the head comes first, the body being held as far as
possible out of the way by an assistant during their
application and use. The usefulness of the forceps in
these cases, is, however, questionable. Only under
exceptional circumstances can the child live during
the time requisite for their application. If, how-
ever, manual extraction should fail, it is commonly
advised that they should be used, though Schroeder,
for example, does not even mention the possibility of
their being required. It is worthy of note that
Barnes, p. 75, in speaking of their application to the
after-coming head at the brim, says : " The head is en-
gaged with its long axis more or less nearly in the trans-
verse diameter of the brim. The blades should grasp
it in an oblique diameter, approaching the antero-pos-
terior.'' If this is difficult when the head comes first
it is much more difficult in head-last labors. Neither
is it true in any but deformed pelves that the head
enters the brim transversely, for it enters either the
right or left canal in the same fashion as when it
comes first ; except that it is upsidedown. The head
should therefore, if possible, be grasped by the for-
ceps in the same way, but the body and neck of the
child are so much in the way, that if manual efforts
to deliver tlie head fail, the forceps will rarely suc-
ceed, and craniotomy will be the only resource. Meigs
THE APPLICATION OF THE FORCEPS. 119
taught that the practitioner should always carry the
forceps to every case^ lest in a breech case the child
should die before we could get them. But, highly
as I esteem the instrument, I fear that they have
saved few lives under such circumstances.
IV. A few general remarks upon the application
of the forceps in any case may here be made. First,
they should not be introduced during a " pain '^ or
uterine contraction. The passage of the blade
through the cervix will often excite a contraction,
which speedily subsides if the manipulation is sus-
pended, after which it may be renewed. Secondly,
the use of anaesthetics is neither necessary nor advisa-
ble. The introduction of the forceps is not painful,
or at least no more painful tlian an ordinary uterine
contraction. The sensations of the woman are also
an invaluable guide and safeguard during their intro-
duction. If you are causing pain it is probably be-
cause you are not passing the blade properly, and the
exclamations of the woman will speedily notify you
of the fact. When the blades are locked, you are in
no danger of pinching the maternal tissues if the
locking is painless. But if the woman is anaesthet-
ized you are left entirely to your own discretion.
Although a careful and skilful operator will not do
any harm with them under any circumstances, it is
much better for the beginner to use them upon a
thoroughly conscious individual. After they are
once applied there is no reason in the operation itself
120 HOW TO USE THE FORCEPS.
why an anaesthetic should be withheld-, though I
would still oppose its use, for reasons foreign to the
matter in hand, and therefore inappropriate for dis-
cussion in these pages. Thirdly, the forceps should
never be taken up with the determination to apply
and use them '' whether or no." The beginner, and
indeed the more experienced practitioner, will occa-
sionally attempt to apply them in an unsuitable case.
If when he finds that a blade does not go on readily
or that the blades cannot be made to lock, he loses
his self-control, and dripping with perspiration at-
tempts to force circumstances and the forceps to
obey his will, he will surely do damage. Force is
never needed in their application. If they are passed
in the right direction they will find their place in
every suit'xble case. Gentleness and skill are the
needed elements, and never force. If these fail, let
the physician send for some one else, since two heads
are better than one. Or, if he is remote from assist-
ance, let him suspend his efforts for a while, medi-
tate upon the cause of failure, and try again.
Fourthly, if the blades will not lock readily, it is
usually the fault of the second blade, which should
be taken out and reapplied instead of attempting to
force the blades into locking. If, after due trial, the
locking is still impossible, both blades may be taken
out and reapplied, while the position of the head
should again be carefully made out, since a mistake
in diagnosis may have been made, or the positiori it-
self may have changed, as occasionally happens.
TRACTION. 121
TRACTION.
The forcepg having been applied, the next ques-
tion is, what are we to do with them ? Are we to
pull the head out by direct traction, or to pry it out
by leverage, and shall it be compressed during either
of these movements ?
The following propositions may be laid down as
a starting-point : First. If the Davis forceps (or
any other having a sufficient pelvic and head-curve),
are applied to the sides of a head at the inlet in the
first vertex position, the general line of the blades
will be parallel to the axis of the presenting plane of
the head. Secondly, If traction is made in the line of
the blades, the distal ends of the blades will press upon
the head, and if the latter is movable will push it on-
wards in the line of the axis of the presenting plane.
Thirdly. If during traction the line of the blades is
kept parallel with the axis of the canal in which the
head is placed, the axis of the presenting plane of
the head will be kept in coincidence with the
axis of the canal in which it moves. This is what
takes place in normal labor, and this is what it
should be our aim to imitate with the forceps. It
ought not to require a mathematical demonstration
to show that when the head is kept in this exact re-
lation with the pelvic canal it will move with the
least possible expenditure of force. If instead of
this the force be so directed as to push or pull it al.
122 HOW TO USE THE FORCEPS.
ternately against the sides of the pelvis, more force
will be required, unless the laws of mechanics are
altered for the benefit of obstetricians. And yet the
great majority of obstetric writers recommend that
traction be supplemented by leverage, and that the
handles of the forceps should be swayed from side to
side that the head may be pried out as well as pulled
out of the pelvis. From this it may be inferred,
however presumptuous the inference may seem, thai
they do not make traction in the right direction.
Barnes asserts that '' pure traction is almost an im-
possibility," and this is true enough, if the usual di-
rections for the use of the forceps are complied with.
A few selections from authoritative works will be
sufficient to indicate what these directions are, and in
what they result. Cazeaux, p. 970, says : '^ If the
head is at the superior strait, we mast first draw
downwards and backwards as much as possible.''
But how? " In performing the tractions the right
hand is placed near the clams (at the ends), and
above the instrument, the left hand in front of tho
articulation and beneath." Leishmann, p. 4G0,
says : '' The handles should be grasped by both
hands. . . The force should be applied as nearly
as possible in the direction of the axis of that part of
the pelvic canal within which the head lies ; and the
operator should act by combining steady traction
with a swaying motion of the handles from side to
side." Playfair, p. 4G8, says : ^' When once the
TRACTION. 123
blades are locked we may commence our ejfforts at
traction. To do this we lay hold of the handles with
the right hand, using only sufficient compression to
give a firm grasp of the head and to keep the blades
from slipping. The left hand may be advantageously
used in assisting and supporting the right during our
efforts at extraction, and at a late stage of the opera-
tion maybe employed in relaxing the perineum w^hen
stretched by the head of the child. Traction must
always be made in reference to the pelvic axes, being
at first backwards, towards the perineum, etc.'' And
so on through obstetric literature. From these
meagre directions we learn that we are to pull upon
the handles, and at the same time to see that the pull-
ing is in the axis of the pelvis, *' as nearly as possi-
ble." That it is not possible seems to be quite gen-
erally suspected. Hence the direction of Meadows,
J). 224, '' When using curved forceps, we sliould pull
less with the handles than with the part of the for-
ceps between the handles and blades." In which
case we would insensibly do something else than pull,
as will be presently alluded to. Hodge also, p. 253,
hints that, '" While the practitioner always keeps his,
right hand on the handles, the left may be variously
employed, sometimes in front of the shanks, so as to de-
press the whole head toward the coccyx and perineum,
tlien again the fingers may be applied to the head ol
the child to watch its progress, and eventually to the
perineum, so as to prevent mischief from laceration.
124 HOW TO USE THE FORCEPS.
etc., at the time of birth." But in the directions for
traction we have only a reiteration of the advice to
make traction and in the pelvic axis, with the lever-
age superadded. I have not the slightest doubt that
the practice of Dr. Hodge was superior to his pre-
cepts, and Lusk says : " Many indeed seek to pre-
vent the anterior pressure of the forceps by placing
the left hand upon the lock and using it as a fulcrum
around which rotation is effected.'^ Although there
is no written precept for this, I have seen the forceps
used rightly by more than one who would have stated,
if asked, that he was following the ordinary rules. But
can we, by pulling upon the handles, cause the head to
move in the right direction ? In Fig. 23 we have a
representation of the forceps applied to the head at
the inlet. The line EP indicates in a general way
the line of the blades and also as nearly as can be
shown in an antero-posterior section the first direc-
tion in which the head should move. If we pull
upon the handles, we will pull in the line of the
handles, and every part of the blades as well as of
the head, which is for the moment immovably con-
nected witli the instrument, will move in a line paral-
lel to the line of the handles. Hence even when tlie
handles are well against the perineum and traction
is made directly downwards, the liead will be pulled
against the symphysis pubis. Practically, it is diffi-
cult to avoid elevating the handles somewhat, espe-
cially if the force is great, in which case the head will
TRACTION.
125
be more directly and inevitably pulled against the
symphysis. Between the head and symphysis will be
the bladder and cervix uteri, which will suffer more
or less, according to the amount of force employed,
Fig. 23.
while the head will not be advanced. Notwithstand-
ing these facts, there are some teachers who delib-
erately advocate the most powerful traction with both
hands upon the handles of the forceps.
I extract from current medical literature a case
which shows that this teaching is carried into prac-
126 HOW TO USE THE FORCEPS.
tice, and that it sometimes accomplishes delivery.
The writer has gone to his account. '^ On the 2d of
March, I attended to a Mrs. M., a multipara, third
child. The two first were delivered by craniotomy.
The vertex presenting K. 0. A., and impacted be-
tween sacrum and pubes ; the conjugate diameter of
superior strait greatly contracted. I applied forceps
and had considerable difficulty in locking them.
Dreading the laceration which might ensue, in this
case, from side-to-side lever action, I concluded to
rely entirely upon direct and steady traction. My
strength giving way, her husband held me around the
waist, whilst the patient was held in situ on the dor-
sum, by four women. In forty-five minutes I had
the satisfaction of bringing the head down on the
perineum. The delivery was then speedily accom-
plished. Both mother and child, a girl, did
well." This is simply horrible, and yet the child
was born and the mother recovered. Two circum-
stances probably determine the delivery when the
forceps are used in this manner. In the first place
the head finally slides off from the pubes as from an
inclined j^lane. But the amount of force requisite
for this is very many times greater than that wliich
would be required if the traction were made in the
right direction. In the second place, the head being
pressed against the cervix, irritates the uterus into
making powerful contractions, which both impel the
child in the proper direction and to some extent de-
TRACTION.
127
fleet the tractile force of the forceps. The power
which the forceps have in determining uterine con-
tractions by the mere fact of their presence is an im-
portant fact, and in many cases greatly diminishes
the amount of force required from the forceps them-
selves.
Among the first to have a practicable doubt as
to the possibility of making traction upon the han-
dles in the proper direction was Tarnier, who accord-
ingly invented a pair of forceps with a considerable
pelvic curve, which was fitted with steel rods affixed
to the lower edge of the blades,
so that we could pull in the line
of the blades and not in that of
the handles. This is an unne-
cessarily ingenious contrivance,
since we possess in the ordinary
forceps all that is necessary if we
will use them correctly.
The method which seems to
me to be the correct one, I will
now attempt to describe. When
the forceps are applied at the in-
let the handles are seized by the
right hand from above and held
firmly, compressing the head as
little as possible at first. The ^^^- ^•
left hand is placed so that the ball of the thumb
comes over the lock (see Fig. 24), while the index-
128 HOW TO USE THE FORCEPS.
finger rests upon the upper arm of one blade, and the
middle finger upon the other. Xow, while the right
hand holds the handles almost at rest, the fingers of
the ]ett push upon the blades so as to move them and
the contained head downwards, backwards and a lit-
tle to the left of the median line. Secondly, while
the fingers are pushing downwards in this way, we
may also make use of them as a fulcrum, and by ele-
vating the handles cause the blades to move in an
opposite manner, but care must be taken that the force
thus applied by the right hand is not enough to over-
balance the downward pressure of the left, else we
will merely extend the head without propelling it.
It is sometimes convenient to vary the position of
the left hand and fingers, but the principle is the
same, that pushing and not pulling is the first step
in traction. When the head begins to descend we
may place three fingers between the blades, the
thumb and little finger being upon the outside, and
combine a pulling with a pushing motion upon the
blades. But throughout the handles are simply ele-
vated and not pulled upon, or but slightly, having
due regard to the proper direction, and bringing
them into the median line only when the head has
reached the inferior strait. When the head is deliv-
ered the handles will lie upon the abdomen of the
mother. This, in brief, is the method which I cm-
ploy and advise. When we consider the compara-
tively small amount of force which the fingers can
TRACTION. 129
exert^ it is in marked contrast to the method of em-
ploying the united efforts of two men in pulling upon
the handles, and will scarcely be credited with suffi-
cient power by those who are accustomed to use
much force. But when we reflect upon the state-
ments of Poppel and Kristeller, that a force of from
four to eight pounds is often enough to expel a head
that had lain immovable for hours, it is evident
that traction in the right direction need not be very
forcible. For the forceps are used perhaps oftener
for simple uterine inertia than for any other reason,
and it is especially in these cases that I recommend
this method. And it is also evident that traction
which impels the head against the joubes instead of in
the proper pelvic axis must always be unnecessarily
powerful in every instance. When this method is
carefully and patiently carried out, i t will rarely fail
to deliver if the case is a suitable one for the employ-
ment of the forceps. But there are occasionally met
with cases in which more force is demanded^ in
which the method must be modified. In such cases
we may pull upon the handles with the right hand
and with such force as may or can be exerted, while
at the same time we endeavor to deflect the force in
the proper direction by pushing upon the blades in
front of the lock with the left hand, at the same
time making use of the leverage above described.
But under no circumstances will it be necessary to
pull upon the handles with both hands, or put the
130 HOW TO USE THE FORCEPS.
foot against the bed, or secure additional help in
traction. If the force which can be exerted in the
right direction in this way is incompetent to deliver
the child, no amount of force wrongly applied will
succeed without injuring the maternal tissues to an
utterly unjustifiable extent.
Having defined what I mean by traction, the details
of the operation may be enumerated. The tractile
efforts should be made during the continuance of
the labor pains, if the latter are frequent and regular,
and suspended in the interval between them. But as
the pains will rarely be of this character, it is usually
allowable to pay little attention to them. They should,
however, be imitated, with some exaggeration. Trac-
tion may be made during one or two minutes, and then
suspended during two or three minutes. There are
several reasons for the intermission. In the first place,
continuous pressure will be undesirable for the mother,
and will weary her. To give rest between the efforts
is therefore necessary. Secondly, it either dilates the
vaginal tissues too rapidly, if we succeed in continu-
ously advancing the head, or it interferes too much
with the circulation in tho parts in advance of the
head if the latter does not advance. If the pressure
is intermittent this is avoided. Thirdly, there will
be more or less compression of the head in every case.
If the traction is continuous the compression, what-
ever its degree, will be continuous and the circula-
tion in the child's brain will be dangerously inter-
TRACTION. 131
fered with as well as that of the parts to which the
blades are directly applied. For this reason it is ad-
visable, whenever we have ceased traction tempora-
rily, to partially or wholly unlock the forceps in
order to take off all compression exerted by them
This is done by sliding the female branch partly or
altogether from under the button of the male branch.
When we resume traction, the simple grasping the
handles relocks the instrument, and allows us to pro-
ceed as before.
The whole time occupied in traction varies great-
ly in different circumstances. In a simple case
of uterine inertia without disproportion, the only
consideration in the way of immediate delivery
is the due preparation of the soft parts. Ten or
fifteen minutes is all that is usually required by
the multiparous woman for the accomplishment of this
part of labor naturally, and we may conform to this
in using the forceps. Where there is much dispropor-
tion, w^e may have to wait much longer before we can
deliver, during which time the head is moulded, as in
protracted labor without the forceps. I do not think
that any rule can be laid down as to the longest limit
of traction. Ellwood Wilson has kept them on for
eight hours (Am. J. Ob., 1876), using them only dur-
ing the pains and merely to assist the latter. This
is an exercise of patience which would overtask most
of us, and would not be safe as a rule for general ap-
plication. The duration of the second stage of labor
132 HOW TO USE THE FORCEPS.
for eight hours, with the head well in the pelvis, is
not entirely devoid of danger, under any circum-
stances, though when we reflect that the compres-
sion of the head by the forceps really relieves the
maternal tissues to that extent, it is probable that
labor might be allowed to continue much longer
while the forceps were applied than without them.
When we Snd that the head does not advance under
our efforts, made in the proper direction and with full
compression, we may decide when to abandon the
forceps for the perforator by the condition of the
mother. So long as that continues good and the pel-
vic tissues show no signs of injurious pressure, we
may continue our efforts until thoroughly satisfied
that the head cannot be delivered by the forceps. But
in the vast majority of cases, if the forceps can be ap-
plied and locked, they will be competent to deliver,
under an hour. And it cannot be too often repeated
that there is nothing to be gained by becoming im-
patient and hanging with our whole weight upon the
handles of the instrument. So long as force is ap-
plied in the right direction, any amount which can
be exerted may be employed. The safeguard is that !
a great deal of force cannot be applied in the right ,
direction, and if it is used in any other direction it
becomes at once unjustifiable, whatever its amount.
When the head is upon tlie perineum, it is some-
times well to make tractions between the pains, and
not during tlicir continuance. This applies mainly
TRACTION. 133
when the expulsive efforts are violent^ for in that case
the added force from the forceps will favor perineal
laceration. This plan was first suggested by the late
Dr. S. D. Turney, and will sometimes be found use-
ful. There are some who recommend that the for-
ceps should be removed when the perineum has be-
come greatly distended, for fear of laceration.
The forceps give us such a thorough control over
the head and its movements that I believe they are a
great help to prevent rather than to cause this acci-
dent. We can hold back or advance, flex or extend
the head with entire ease, as may be needed. But to
do this successfully requires coolness, judgment, and
quickness, and a wrong turn of the forceps at the
critical moment will certainly cause a laceration if
this is at all imminent. If a person is not quite sure
of himself, he had therefore better take them off
rather than wield a power potent for evil as well as
good. When they are removed the head may be ex-
tracted by the form of rectal manipulation known as
the Eitgen-Goodell method, although Smellie (Coll.
19, cases 1-2) described and used it, and gave the
credit to Ould. Two fingers are introduced into the
rectum and placed upon the forehead of the child,
while the thumb of the same hand, or fingers of the
other hand, are placed upon the occiput through the
vulva. The head is then manoeuvred out in a manner
easier to perform than to describe. When this is
done during the absence of a pain we certainly escape
134 HOW TO USE THE FORCEPS.
from rupturing the perineum, so far as the head is
concerned.
In taking off the forceps when the head is on
the perineum we consider mainly the head-curve
of the instrument. Having separated the lock, one
of the handles is moved across the median line so as
to lie in the groin of the opposite side, which will
cause the blade to glide out of the vagina without dis-
turbing the head at all. The same is done with the
opposite blade in the contrary direction. When for
any reason it becomes necessary to remove the for-
ceps at a higher level, the pelvic curve may have to
be considered, or in other words the blades are with-
drawn in the same manner in which they are applied,
with a reversal of direction.
COMPRESSIOK.
•
The utility of the forceps as a compressor is
beyond question, since the bi-parietal diameter is
capable of being diminished by their use from a
half inch to an inch. As we can reduce the antero-
posterior diameter in another way, Ave can by com-
pression greatly facilitate delivery. But when the
forceps are not applied to the sides of the head we
must be very careful how we use compression on the
living child. Tlie question in such a case is not so
much whether we can diminish tlie size of tlie head
by compression, but whether we will not cut and in-
jure the head by it. Wlien applied to the sides of
LEVERAGE. 135
the head, and this should include the great majority
of cases, compression carefully performed is entirely
innocuous and of great benefit. It should in every in-
stance be performed slowly, evenly, and gently, and
should be maintained only for a minute or two at
most, with an interval of relaxation following. If
the head is suddenly squeezed in the forceps, or if the
handles are tied together, as the manner of some is,
harm will be done as a matter of course. But if ef-
fected as stated above, the full compressing power of
the instrument may be exerted without injury to the
child. I have been surprised to find after the fullest
compression, but intermittently applied, that not
even a temporary imprint of the blades could be dis-
covered upon the child's head within ten minutes af-
ter its delivery. I do not think that anything is ever
gained by continuous compression. The head can
be moulded to much better advantage, even in the
most difficult cases, by systematically intermitting
both traction and compression, even when the ques-
tion of the child's life is not under consideration.
LEVERAGE.
The action of the forceps as a lever may be in-
voked in some cases, for the purpose of flexing or
extending the head, but I hasten to add that it is
not to be used to pry out the head by ^^ to and
fro/' leverage, as is so generally taught. Denman,
p. 376, recommended to use the forceps almost
136 HOW TO USE THE FORCEPS.
exclasively as a lever. '' The first action with them
should therefore be made by bringing the handles,
grasped firmly in one or both hands, to prevent the
instrument from playing upon the head of the child,
slowly toward the pubes, until they come to a full
rest. Having waited a short interval with them in
this situation, the handles must be carried back in
the same slow and steady manner to the perineum,
exerting as they are carried in the different direc-
tions, a certain degree of extracting force ; and after
waiting another internal, they are again to be raised
toward the pubes according to the situation of the
handles." As this would only alternately flex and
extend the head, as well as interfere with any right
direction of traction, it is no wonder that Denman
preferred the vectis, about the use of which he ap-
pears to have had a more intelligent understanding.
The more modern method is known as the " pendu-
lum leverage" or " lateral oscillations," and consists
in swaying the blades from side to side while making
traction. This is supposed to act on the principle of
the ratchet. One side of the head is brought down
and is expected to stay down while by a reversal of
the instrument the other side is brought to the same
or a lower level, and so on until it is extracted.
Barnes claims to be able to deliver in this wav al-
most without any traction. Even if it were true
that this method of leverage was preferable to trac-
tion in the pelvic axis, and advanced the head, it is
LEVEKAGE.
137
pertinent to inquire how this is effected. If it is
done at all, it must be by making each side of the
pelvis alternately a fulcrum, against which the for-
ceps are pried. As J. Matthews Duncan says, there
is no toothed rack in the pelvis. Therefore, when
we bring down one side of the head we must press it
with great Brmaess against the pelvic walls if we ex-
pect it to retain its position while the other side of the
head is being brought down. In other words, the steel
blades of the forceps or the parietal protuberances are
alternately jammed against the maternal tissues inter-
vening between them and the pelvic walls upon each
side whenever this delectable
form of leverage is resorted to.
And this happens whether the
head really is advanced by it or
not. That it does not advance
the head seems to me to have
been so clearly shown by Dr.
A. H. Smith that I take the
liberty of quoting largely from
his paper (Fig. 25). " Let PW
and P'W be the pelvic walls
in section made in the plane of
tiie maximum diameter, and of
that transverse diameter, the
ends of which are grasped by
the blades. Let MM' be the ^.o. 25.-apteb a. H. Sm.tb.
maximum diameter, corresponding with the axis
138 HOW TO USE THE FORCEPS.
of the canal, GD the transverse (whether bi-parietal
or other) these two crossing each other at A, which
will then be the centre of oscillation of the head in
any pendulum movement of the handles and the cen-
tre of motion in a direct traction. Let us draw
through this centre two oblique diameters, 00, O'O',
and also from the extremity of the line GD an
oblique line to a point 0, on the periphery of the
head nearer to M'. FBB' will represent the blades
of the forceps through the fenestra of which the tis-
sues of the scalp should protrude sufficiently to rest
firmly against the pelvic walls, unless the blades be
narrow, when the scalp tissue will come in contact
with the pelvis at the sides of the blades. . . .
What will be the effect of pure oscillation, or leverage
as it is called, with compression, but without trac-
tion, the method recommended by Dr. Barnes ? The
first movement, say, will carry the handles toward W ;
the head, then, being ' immovably united to the for-
ceps,' must rotate upon an axis passing through A,
perpendicular to the transverse GD, which transverse
also rotates, the extremity G moving upward toward
P, and the extremity D correspondingly descending
toward W. But as the diameter GD moves, so does
the oblique diameter 00, passing through A, move
also proportionally ; 0 following G upward, as 0 fol-
lows D downward, and the extremities of this oblique
diameter come to assume the position, in relation to the
nlane of the pelvis occupied before this lateral move-
LEVERAGE. 139
ment, by the extremities of the transverse diameter.
But we know that every oblique diameter of an ovoid
passing through the centre of the greatest transverse
diameter is greater than the transverse, and that the
increased length is proportionate to the distance of its
extremities on the periphery from those of the trans-
verse. The more considerably, then, we move the
handles towards W, the more we place the longer di-
ameter of the head in the position originally occu-
pied by the transverse diameter. As the handles
swing back, approaching the median line, the diam-
eter in relation with the jilane diminishes until the
handles pass the median, and are made to approach
W ; when the same clumge takes place in the bearing
of the extremities of the oblique diameter O'C, and
this diameter takes the place of the transverse against
the pelvic walls. Here, then, we have a demonstra-
tion sufficiently clear . . . that oscillation with-
out traction simply brings to press upon the pelvic
walls, with a sort of slow vibratory impact, portions
of the head farther separated from each other than
the points which rested in contact with those walls
before the swaying motion was started ; that while
the pelvic wall is subjected to alternations of exces-
sive pressure and partial relief, there is nothing in
the movement itself to advance the head an iota, the
side which descends with the swaying of the handles
in one direction, ascending equally (unless driven
down by the vis a tergo, which acts altogether inde-
140 HOW TO USE THE FORCEPS.
pendently of it) when the handles are swayed in the
opposite direction."
In the same manner he demonstrates that
'^ leverage with traction is simply traction plus
an aggravation of pressure upon surfaces already
so tightly compressed by the circumference of the
child's head as to obstruct its advance toward the
outlet of the pelvis. '^ As I have already shown, the
proper direction of traction at first is not in the
median line, but somewhat to one side, in the axis of
the canal in which the head is placed. With every
other lateral oscillation therefore, the head is so far
forth impelled by the coincident traction in that axis,
which may account for the success in delivery which
is claimed for this method. But it is hardly neces-
sary to add that it is not expedient to subject the
mother's tissues to pressure for the sake of occasion-
ally making traction in the right direction, when it
is equally easy to make it directly and uniformly in a
proper manner.
The forceps have a proper use as a lever ; first in
flexing the head.
a, Flexion. — A delay in the flexion of the head may
be and not infrequently is the sole cause of delay in
the advance of the head. AVe may, in such a case,
apply the forceps and by simple traction deliver, but
as the occipito-frontal diameter is thus kept coinci-
dent with the successive pelvic planes, unless the
head is spontaneously flexed in transit by the influ-
LEVERAGE. 141
ence of the pelvic walls, a greater amount of force is
required to deliver than if the cervico-bregmatic di-
ameter had been substituted. Preliminary flexion
of the head is therefore very desirable. If the head
is not flexed the blades of the forceps are not parallel
to the occipito-mental diameter of the head when ap-
plied, which should be the case when the head is thor-
oughly flexed. After applying them in such a case,
then, before thoroughly locking the instrument,
we may elevate the handles. This will allow the
blades to glide over the head and become joarallel to
the occipito-mental diameter. We then slowly and
firmly compress the head with the handles in this
position, and when the head is thoroughly grasped
we return the handles to their original position, press-
ing against the perineum, at the same time pushing
them gently farther into the pelvis in order to slight-
ly lift the head from the brim while the movement is
being made. This will flex the head, so that in some
cases the amount of force required for extraction will
be very slight, if indeed, the uterine efforts are not
entirely sufficient. This manceuvre in competent
hands is devoid of danger, but the blades must be
upon the sides of the head, and we must, of course,
accurately know the position of the head before at-
tempting to change it.
In occipito-posterior positions the same principle
may be brought to bear with great advantage. The
rotation of the occiput forward is promoted by ex-
142 HOW TO USE THE FORCEPS.
treme liexion. At the very beginning, we then, may
secure this in the following manner : The handles
are pressed back firmly against the perineum, as each
blade is introduced. The head is then carefully
grasped and the handles elevated. Traction is then
made with the liandles in an elevated position in
order to keep the head flexed as much as possible. A
similar elevation of the handles is sometimes useful
during the perineal stage of an occipito-anterior posi-
tion in order to extend an unduly flexed head. The
application of the same principle in facial positions
is sufficiently obvious, as well as in a condition of too
great lateral obliquity in the vertex loositions. As
compression reduces the bi-parietal diameter, and
flexion shortens the antero-posterior diameter, the
combination of the two procedures decreases the en-
tire circumference of the head.
i, Rotation, — It is also possible to use the forceps
to rotate the head, but this a23plication of the instru-
ment is rarely proper or useful. In occipito-anterior
positions the pelvic walls will effect rotation much
better than we can, if we are careful to make the trac-
tion in the right direction. All we need do is to see
that we do not hold the handles in such a manner as
to interfere witli rotation. But in occipito-posterior
and mento-posterior positions the desirability of
early anterior rotation is so apparent tluit there is a
strong temptation to bring it about with the forceps at
all hazards. In these positions, when the liead is at
LEVERAGE. 143
the inlet, it is highly improper to attempt anterior
rotation with a pair of forceps having a decided pel-
vic curve. The form of the instrument distinctly
prohibits this.
The voice of experience is equally clear against
making the attempt with the straight forceps. If
then we cannot secure anterior rotation by manipu-
lation, either internal or external or both combined,
we may apply the forceps to the sides of the head as
it lies and make traction in the axis of the canal in
which it is placed without any present reference to
its rotation. We should exert as little compressing
force upon the head as possible, for this reason.
When the head nears the inferior strait it tends to
undergo anterior rotation according to a mechanism
described in a preceding section. As the parietal
protuberances project through the fenestra of the
blades the mere presence of the forceps does not in-
terfere with this, and anterior rotation may take
place by the head turning inside the blades of the
forceps. This has not unfrequently been noticed.
Decided compression tends to allow the head to come
down without sufficient contact with the pelvic walls
to compel rotation, especially if the tractile force is
considerable at the same time. The fact of its oc-
currence will be generally indicated by a tendency of
the blades to slide together posteriorly, when the for-
ceps are unlocked in the intervals of traction. For
as a uterine contraction comes on, before the forceps
144 HOW TO USE THE FORCEPS.
are locked the head, in attempting to rotate, carries
one of the blades with it, leaving the other station-
ary. This at least is the explanation I have framed
from observing the phenomena, though it is not en-
tirely adequate. For under these circumstances it
may happen that as soon as the forceps are unlock-
ed, and when there is no uterine contraction, the pos-
terior edges of the blades at once approximate, which
perhaps shows that during the last traction the head
was prevented from rotating anteriorly by the man-
ner in which the forceps were held ; but as soon as
it is released from their influence it rotates, carrying
one of the blades with it. If the position of the
blades is not much altered they may be carefully
made to come opposite to each other without with-
drawing them, but if their relative position is much
disturbed, it is an evidence that anterior rotation is
nearly or quite complete, and they may be withdrawn
and re-applied as in an anterior position. I have
witnessed these changes taking place during the de-
scent of a mento-posterior position, and have re-ap-
plied the forceps accordingly. The innocuousness
of the proceeding was shown by the fact that not
even a temporary imprint of the blades was discover
able upon the head immediately after birth. If the
head is large it will not rotate within the forceps,
but may rotate with them. It is in just such cases
that it seems most plausible that we should force an-
terior rotation with the instrument. For if it fails
LEVERAGE. 145
to occur we will have to drag the occiput over the
perineum, or in the case of the mento-posterior posi-
tion be utterly foiled in the delivery. Nevertheless,
forced rotation will almost invariably prove to be a
meddlesome interference. And although the situa-
tion seems to call for the limit of tractile force, we
should also be very chary of this as well.
If traction is very powerful at this juncture, com-
pression will almost certainly be also carried to its
extreme limit, and we may pull the head through the
inferior strait posteriorly and destroy all hope of an-
terior rotation. What is needed is moderate and
patient traction, and a slight motion of rotation ; so
slight as to be of little service for effecting a change
of position in itself and only to test the inclination
of the head. If the head is manifestly inclined to
rotate it may be .2:ently assisted, but force will do no
good and may do harm. The head and the pelvic
walls between them will determine the exact level
and time at which rotation can be effected much bet-
ter than we can, and we should therefore only assist
it when actually being performed and not prema-
turely urge it. When the head is at the inferior
strait so much of the blades are exterior, that the
intra-vaginal portion of the instrument is sufficient-
ly straight to make it entirely proper to allow the ro-
tation to take place with the forceps applied. But
when it has occurred they should be withdrawn,
when they may be re-applied, or the case left to the
146 HOW TO USE THE FOKCEPS.
uterine contractions. There are two principal rea-
sons for not attempting to force rotation. In the
first place rotation is normally accompanied by de-
scent. The head begins to rotate at the level of the
ischial spines, but at the end of the movement may
have reached the perineum.
The exact proportion of descent and rotation in a
given case is determined by circumstances which we
know nothing about in a given case, and not even a
skilful operator can cause the head to rotate anteri-
orly as well as the natural conditions spontaneously
bring about. On the contrary he may impede the
process by his efforts. In the second place, a cer-
tain proportion of cases cannot be rotated ante-
riorly without twisting the neck of the child to a
fatal extent, and doubtfully even then. When the
back of the child's body is posteriorly situated in
the womb this is true, and this cannot always be
known beforehand or remedied by manipulation.
To patiently make moderate tractions in such a way
as not to interfere with rotation, and to keep the
head well flexed, should be our aim in occipito-pos-
terior positions.
WHEN TO USE THE FORCEPS.
The forceps may be used under the following cir-
cumstances.
I. For delay in the second stage of labor, arising
from : a, uterine inertia ; Z>, small size of vagina ; r,
WHEN TO USE THE FORCEPS. 147
rigidity of maternal tissues ; d, obstructions from
bands, etc. ; e, large size of head ; f, want of flexion ;
g, pelvic deformity.
II. For delay in the first stage occasionally, as in :
a, placenta previa ; 5, rigidity of the os uteri ; c,
absence of a natural dilating agent.
III. For certain accidents of labor, in any stage,
and when rapid delivery is indicated, as : a, convul-
sions ; h, prolapse of the funis ; c, excessive uterine
action menacing rupture.
IV. For certain secondary purposes as for : a,
extraction of the child after rupture of the uterus ;
h, after gastro-hysterotomy or elytrotomy ; c, for re-
moving tumors and foreign bodies from the maternal
passages.
The forceps have been and may be used for any of
these conditions, though the advisability of their use
in a given case must depend upon the individual cir-
cumstances then present, and not entirely upon a
general rule.
I. It is first' in order to define what is meant by
delay in the second stage, or what measure of delay
calls for the use of the forceps.
When the^ os uteri has become fully dilated and
the liquor amnii has escaped, the great majority of
multiparous women are delivered within a few min-
utes. A second stage of five or ten minutes' dura-
tion is very frequently observed and fifteen minutes
is probably above the average in normal labor. In
148 HOW TO USE THE FORCEPS.
primiparae, the dilatation of the vagina and peri-
neum usually takes up more time, so that from a half-
hour to an hour is not far from the average in this
class of cases. The length of the first stage has little
to do with that of the second. A first stage of
twenty-four hours may be followed by delivery in ten
minutes, when once the os uteri is dilated, and a first
stage of two hours may be followed by a second stage
of many hours. The second stage may be protracted
from any of the causes mentioned under this head at
the beginning of the section, the most common of
which is uterine inertia, or a want of siifficieyit pro-
pulsive power, for the term is a rather relative one.
If the case is protracted beyond the average limit
we may ask ourselves three questions : First, What
harm does the delay do ? Second, Can we safely inter-
fere ? Third, Of what advantage to either the mother
or child will the leaving the case to " Nature " be ?
First. Delay in labor, especially in the second
stage, injures the mother and child in direct propor-
tion to the length of its continuance and the depth
to which the head has descended in the pelvis. Each
expulsive effort is attended with an expenditure of
vital force, while at the same time the functions of
digestion and assimilation are so interfered with that
the drain cannot be kejit up indefinitely. The
woman is weaker with each pain. Tliis is pro-
vided for in normal labor. The ideal woman during
an ideal pregnancy becomes more robust and vigor-
WHEN TO USE THE FORCEPS. 149
ous during the wliole gestation. She enters upon
labor with a reserve of physical force entirely ade-
quate for its performance, so that when delivery is ac-
complished she may arise, cleanse herself and the
baby, and resume the ordinary functions of life with
unimpaired vigor. But the ordinary civilized wom-
an with whom we have most to do, finds even an
ordinary labor a rather exhausting piece of work,
and if it is at all long she requires a proportionately
longer time in which to recuperate. Also, the aver-
age woman does not on]y approach labor with a very
slight, if any, reserve of physical force, but is too
often even below par at this time. Her urine is apt
to be albuminous, lier blood hydraemic, her digestion
impaired, and if she is, under such circumstances,
subjected to a long and tedious labor, she is in a ripe
condition for all the diseases incident to the puer-
peral state. So far, then, as the expenditure of
vital force is concerned, the sooner the woman is
through with her labor the better. She is not only
using up her strength by muscular contractions, but
she is kept in mental suspense, and is not usually
able to repair her energies by the taking of food.
The continuance of the second stage also involves the
pressure of the head of the child against the soft tis-
sues of the mother, with an increase of the pressure
during each pain. This pressure is least when the
head is movable at the inlet, but increases in its ca-
pacity for evil at least, with each fraction of descent.
150 HOW TO USE THE FORCEPS.
Its continuance may result in destroying the vitality
of the tissues pressed upon. It is the most common
cause of vesico-vaginal and other fistulas and pre-
disposes to the occurrence of pelvic inflammation
after labor. When the head is long detained at the
inlet the anterior lip of the cervix is apt to become
cedematous, which may occur to such an extent as to
make it a further impediment to delivery. When
the head is long detained at the inferior strait, or on
the perineum, the latter structure often becomes
boggy and inelastic, and is very apt to become lacer-
ated subsequently. The irritation caused by the
pressure of the head upon these structures, which are
delicate and amply supplied with nerves, is apt to
give rise to convulsions. The child's life is also en-
dangered, especially w^hen the detention is at a low
point, for not only is the direct compression harmful
but the uterus may grind off the placenta and thus
destroy the child. That all these evils follow in the
train of delay is universally conceded ; but to come
to an agreement upon the time when the danger is
imminent rather than prospective is more difficult.
Before attempting to fix the danger line w^e may pass
to the second question, " Can we safely interfere?"
This depends upon the questioner. If he is ignorant
of the anatomy and physiology of the structures in-
volved, of the mechanism of labor, and of the nature
of the forceps, he ought not to interfere even by
his presence. But any one who is really qualified
WHEN TO USE THE FORCEPS. 151
to attend upon the parturient woman can interfere
with perfect safety to mother and child.
The mere application of the forceps contains not
a single element which is detrimental, and is not
even painful. After they are applied they can hard-
ly be said to touch the mother during traction, since
the opposed surfaces of the head project through the
fenestra. It is not therefore the forceps, but arti-
ficial traction, which is to be found fault with if the
operation is objected to. The woman is unable to
expel the child, for a want of expulsive power. We
supply this power and the woman is delivered speedily
instead of waiting iu definitely at great expense of vital
force. Statistics are not alwavs reliable, and I refer
those who put their trust in them to papers by Ed.
S. Dunster* and A. M. Fauntleroy,f merely citing
one specimen. In the Rotunda Hospital, Collins
used the forceps only once in 694 cases of labor, with
a foetal mortality of 1 in 26 and a maternal mortality
of 1 in 329. Harper used them once in 26 cases,
with a foetal mortality of 1 in 47 and a maternal mor-
tality of 1 in 1490. The average duration of labor
was, in the first case, 38 hours, in the second, 16
hours. Barnes (Obst. Oper., p. 280) says : '' Properly
speaking, the mortality from the forceps is nil.
Women die because the instrument is used too
late."
* Proceedings of Michigan State IMedical Society, 1878.
f " A^merican Journal of Obstetrics, " January, 1879.
152 HOW TO USE THE FORCEPS.
We gain further light from the answer to our
third question, ^' Of what advantage will it be to
leave the case to Nature?" The usual answer is,
that we avoid the dangers of rapid delivery, allow the
maternal tissues to be properly " prepared," and
lastly, w^e leave the case in the hands of " Nature,"
who or which is all-competenfc and of benign ten-
dencies. It is difficult to deliver with the forceps in
less than ten minutes in any case, and thousands of
women are naturallv delivered in less time. The
operation usually excites uterine contractions, and as
a matter of fact, post-partum hemorrhage is rare
after a forceps delivery, even when they have been
applied on account of uterine inertia. And in the
matter of preparation, when the labor has continued
for an hour or so during the second stage, the tissues
will be i:)rogressively unprepared and unfitted for de-
livery the longer it continues. A head stationary
in the pelvis, at any point, is progressively congest-
ing and infiltrating the tissues below it, and not pre-
paring them. If it is not stationary, but is advanc-
ing with each pain, the pelvic canal is so short that
there will be no delay. The truth is, that refuge is
taken in a vague appeal to the powers of Nature by
those who are too indolent to learn how to render as-
sistance to the mother. In the words of the late Dr.
Turney, " It sounds well to talk of trusting to Na-
ture. It is sweetly suggestive of green fields, of
flowery meads, of singing birds, of the gentle lullaby
WHEN TO USE THE FORCEPS. 153
of breeze and falling waters, and brings to mind all
the pleasant sights and sounds which amuse us in a
summer's ramble/' But what are the facts ? Nature
has ordained that woman shall be safely delivered in a
few hours. The defiance of the laws of Xature for
generations has brought it about that the woman is
unable to deliver herself without undergoing great
danger. And if we were to leave all cases to Nature
a great many women would die undelivered under
this benign regime. It is not to Nature that we
leave the woman, it is to the consequences of physi-
cal deterioration incurred in defiance of her laws. I
cannot see what advantage there is in this, when we
possess safe and efficient means for rescuing her and
the child from these consequences.
The los^ical deduction to be drawn from these
premises is, that when the os uteri is fully dilated,
the child should be expelled promptly ; and in the
time observed to be usually consumed in normal la-
bors. If it is not, the longer the labor continues the
more danger the woman and child incur, and con-
versely, the sooner she is delivered by the forceps,
the less risk will they run. While these deductions
are fully warranted by the physical facts involved,
they are subject to modification from certain consid-
erations of a practical character. Many women have
a horror of " instruments '' and '' operations," and
will be unfavorably agitated by the early suggestion
of their employment. Also, in the existing state of
154 HOW TO USE THE FORCEPS.
lay intelligence, if anything whatever should go
wrong with the woman after their employment, the
physician and his forceps will have to shoulder the
blame. On the other hand, Cazeaux mentions that
the pains of women are sometimes greatly increased
by the statement that the forceps must otherwise be
used. Having due regard to these considerations,
the following rule seems to me to be proper.
Whenever the second stage of labor has lasted
two hours and the head is still stationarv or ad vane-
ing with great slowness, we should inform the patient
that we are about to apply the forceps. If we ex-
plain the necessity and propriety of the operation we
will rarely find any objections, especially if the
woman is already tired of her fruitless sufferings.
This rule may be deviated from according to the cir-
cumstances of each case, but it will more often be
proper to shorten it than to protract the time of
giving relief. There is no need of keeping the
woman in suffering for hours solely that she may de-
liver herself, and still less for keeping her under the
noxious influence of an anaesthetic for hours, when
we can safely extract the child at will.
These remarks apply to all cases of delay in the
second stage of labor, but it is necessary to qualify
them in some particulars. Thus, in obstruction
from cicatrical bands, persistent hymen, and the like,
it may be necessary to incise the obstructing mem-
brane before applying the forceps. More often, we
WHEN TO USE THE FORCEPS. 155
may wait until tlie band is made tense by the pres-
sure of the head within the forceps, against it, before
dividing it. A head which is enlarged from hydro-
cephalus can rarely be delivered by the forceps as well i
as by a preliminary evacuation of the fluid. But the
forceps are useful as an aid to diagnosis in hydroce-
phalus, since tlie large size of the head is very clear-
ly demonstrated by the wide divergence of the han-
dles when the blades are applied. And if the head is
very large the forcep scannot be applied at all.
In deformities of the pelvis the propriety of
applying the forceps has been brought in ques-
tion, and a few words of justification are in order.
The pelvis is rarely deformed throughout its
whole extent, the deformity being usually limited to
either the outlet or inlet. \^"hen tlic outlet is de-
formed either by the approximation of the ischia or
bending forward of the coccyx, the propriety of
using the forceps is unquestioned. But when the
deformity is at the inlet and is at all considerable,
many prefer version to the forceps. Barnes says (op.
cit. p. 244) that the proper range of the operation of
turning is from 3.25 ^' to 3. 75 ^^ of the conjugate diam-
eter, at the latter point coming into competition
with the forceps. Goodell substitutes version for
the forceps when the conjugate diameter is between
2.75 and 3.25 inches. The limit is variously stated
by different authors, but is recognized by the great
majority as at least equal to the forceps in marked
156 HOW TO USE THE FORCEPS.
deformities and often succeeding when the latter
have failed.
The principles upon which this practice rests
were first stated by Simpson. They are, in brief, as
follows : First, the transverse diameter of the head
can be lessened to a greater degree by the influence
of the pelvic walls when the base of the skull is in
advance than by the forceps when the head comes
first. Second, a greater amount of force can be
employed by pulling upon the body and neck of the
child, combined with supra-pubic pressure, than by
the forceps.
Traction upon the body of the child is ca-
pable of greatly compressing the head. Of this
there is no doubt. It can be exerted to the extent
of producing deep incientations in the parietal bone
by pressure against the promontory. But it has its
limits. Duncan has shown that on an average the
child's neck breaks with a force of 100 pounds and
decapitation ensues when the force reaches 120
pounds. We have then a distinct limit to the
amount of force which can be exerted by traction
after version. The same experimental data are want-
ing for the forceps, but all the force which they can
exert will not affect the integrity of tlie foetal struc-
tures, and there is every reason to suppose tliat a
force of over 120 pounds can, if necessary, be
brought into requisition. The main question is
whether it is true that the bi-parietal diameter can
WHEN TO USE THE FORCEPS. 157
be diminished to a greater extent when the base of
the skull is in advance.
It is alleged that the base is much narrower than
the upper part of the skull, the bi-mastoid diameter
being from four to nine lines less than the bi-pari-
etal. Hence, when the vertex comes first, the head
tends to flatten out, while when the base comes first,
the diameters are progressively diminished during
its progress. This is true enough, but we should
Fig. 26.
contrast the state of affairs in version, not with those
obtaining in unassisted vertex labors, but when the
forceps are used. Which has not been fairly done.
Fig. 26 represents a transverse section of the foetal
cranium. When the base is in advance the com-
pressing force of the pelvic walls will act in the lines
indicated by the arrows A A. But when the forcejjs
are applied to the sides of the head they exert their
compressive force in the lines BB, or directly. To
say that the parietal bones may be made to overlap
158 HOW TO USE THE FORCEPS.
at C by forces acting in the lines AA^ better than
when acting in the lines BB^ is absurd.
Thus we are driven to the conclusion that version
cannot be superior to the forceps, or an elective sub-
stitute for it, when it is possible to apply the forceps
to the sides of the child's head. The difficulty of so
applying them has been, I think, greatly exagger-
ated. The deformity usually occurs upon one side
only of the pelvis, i.e., one sacro-iliac symphysis
only has been affected by disease. As the result,
one of the pelvic canals is impaired or destroyed, but
the other is not necessarily in-
terfered with. Such a state of
things is shown in Fig. 27, from
Schroeder. But when the con-
FiQ. 27. J^^g'^te diameter is reduced to 3
ArTKR scHROEDEK. inclics or less, both of the canals
are impaired and the normal mechanism is entirely
altered. I admit that the difficulty of grasping the
head in its bi-parietal diameter increases with each
degree of contraction below 3 inches, but we can at
least place them obliquely upon the head in every
instance. AVhen this is done, we can bring to bear
upon the head the compressing force of the pelvic
walls nearly as well as Avhen it is dragged down with
the base in advance, and without the risk of breaking
the child's neck, or any of the unavoidable dangers
attendant upon delivery ]>y the breech. And in ad-
dition we will have such compressing and moulding
WHEN TO USE THE FORCEPS. 159
power as is afforded by the forceps. Xevertheless^ if
in any case we find it impracticable to apply the for-
ceps to the sides of the head^ we would be justified
in resorting to version, if the latter were a generally
safe procedure. Since head-last labors have a mor-
tality to the child of at least fifty per cent, and since
version is attended with decided danger to the
mother, especially when performed through a con-
tracted inlet, and also since when it fails we have to
resort to craniotomy at a great disadvantage, this
cannot be claimed. I cannot then conceive of a case
in which version is justifiable as an elective procedure.
If it fails, nothing remains but craniotomy. If after
applying the forceps we have not enough skill to de-
liver, then perhaps version may be tried before the
last resort.
The manner of using the forceps in a deformed
pelvis differs but little from that which is appropri-
ate in the normal pelvis, and that little will be dif-
ferent in each case because scarcely two deformities
are exactly alike. One general feature has been
pointed out by Barnes, viz., that the promontory of
the sacrum usually projects and the head has to
make a curved progress around the promontory be-
fore it can enter the axis of the pelvis, which he calls
the '' false curve of the promontory.'' The effect
of this forward jutting of the promontory I conceive
to be simply to equally push forward the head and
greatly exaggerate the backward direction of the
160 HOW TO USE THE FORCEPS.
pelvic axis. Hence it is often useful to begin our
efforts at extraction in these cases by pushing the
whole instrument downwards and backwards in the
direction of tl^e sacro-coccygeal junction, without
any traction in the ordinary sense of the term. The
exact nature of the deformity cannot always be made
out at the time of labor, but we can always form a
correct idea as to the direction in which the head
ought to move in order to pass the narrowed inlet.
When this is carefully ascertained, we will find that
a comparatively slight amount of force is often
enough to bring the head past the obstruction, after
which it usually progresses without further hin-
drance. It is worth while spending any amount of
time in being certain as to the axis in which the head
is to move, for traction in the wrong direction will
be tenfold more useless in a deformed than in a nor-
mal pelvis.
II. It is sometimes proper to apply the forceps
during the first stage of labor, or before the os uteri is
fully dilated. But although we have advanced in
the obstetric art far beyond the point when a delay
of at least six hours upon the perineum was regarded
as an essential prerequisite to their application, a de-
gree of conservatism is necessary upon this point.
For there are some unavoidable dangers attendant
upon their use during the first stage, and the neces-
sity for their employment should evidently counter-
balance these before we resort to them. These dan-
WHEN TO USE THE FOKCEPS. 161
gers are, first, the possibility of bruising the cervix
during the introduction, which in skilful hands may
be reduced to a minimum ; and, second, the proba-
bility of lacerating the cervix when we come to mak-
ing traction and cause the head to be pressed against
it. For this there is no avoidance except in imitating
the natural course of labor in making the traction
moderately, intermittently, and patiently, so that the
head may evenly and with as little haste as possible
dilate the cervix before passing through the os. And
yet in the very cases in Avhich the procedure is most
likely to be demanded tlie cervix is most indisposed
to dilate without laceration.
The fact that a laceration once begun may extend
indefinitely and end in a veritable rupture of the
womb, makes this consideration too important to be
lightly passed over in deciding upon the use of the
forceps in the first stage. The indications which
suggest their employment are as follows : First, long
delay due to the existence of organic rigidity of the
cervix. The most notable case illustrating this use
of the instrument is one reported by Roper, 1874, in
which the cervix was four inches long and as thick
as a man's wrist. After labor had lasted forty hours,
seven incisions were made, and gradual dilatation al-
lowed to proceed for sixteen hours, after which the
forceps were applied and a living child extracted.
This is an extreme case, but the principles of
treatment are the same in lesser degrees of organic
162 HOW TO USE THE FORCEPS.
rigidity. First, incision, which should not be de-
ferred so long as in this case ; second, a brief period
for further dilatation by the natural powers, and
then, or indeed as soon as the forceps can be ap-
plied, they may be used to further the dilatation by
increasing the force with which the head is pressed
against the cervical rim. If incisions are unneces-
sary, so much the better, but in true organic rigidity
they are usually demanded. The greatest care and
gentleness is called for during traction, which if at
all sudden or violent, would be sure to do harm. In
this way we bring a more efficient dilating force to
bear against the cervix than in any other possible
way. The fact that traction must be made with
moderation, and will probably last for some time, is a
valid reason for resorting to it early in the labor.
We must not wait until the woman is exhausted by
her efforts before we begin, or the desperate nature
of the circumstances will impel us to work faster
than we know to be judicious.
In functional or spasmodic rigidity of the cervix,
which has resisted other methods of treatment, it is
also allowable to apply the forceps as soon as they
can be introduced without violence. There are also
certain cases in which the liquor amnii is early evac-
uated and the head of the child fails to take the
place of the bag of waters as the natural dilating
agent. In cases of unusual pelvic or uterine obliq-
uity, or when from any cause the head is not forced
WHEN TO USE THE FORCEPS. 163
against the cervix after the evacuation of the liquor
amnii, the os fails to dilate. In these cases we will
usually find that the cervix is early dilatable al-
though undilated, and if by external or other manip-
ulation the head cannot be made to engage, it is
proper to apply the forceps, since otherwise the sec-
ond stage is not likely to begin.
The duration of labor in the first stage which
calls for the application of the forceps varies to a
much greater extent than in the second stage. The
first stage is extremely variable in length even in the
same individual in different labors, and its pains can
almost ahvays be endured for a much longer time
than those of the second stage. Hence, a duration
demanding assistance must be determined in each
instance by the condition of the mother. All other
approved means are to be tried before resorting to the
forceps, but if her condition is at all unfavorable,
we should have no concern as to the mere number of
hours which have elapsed, but proceed at once to
render assistance. Another application of the for-
ceps during the first stage is for the comjilication of
placenta previa. It is sometimes recommended to
introduce the forceps after a sufficient amount of di-
latation has been secured, merely to cause the head
to press against the cervix and so arrest the hemor-
rhage. This, to be entirely successful, would require
the head to be constantly pressed against the cervix.
It is much better to first detach the placenta from
161 HOW TO USE THE FORCEPS.
the cervical zone, after the manner of Barnes, after
which the hemorrhage usually ceases. If previous
loss of blood and other conditions make it necessary
to deliver forthwith, the forceps may then be used,
and this application of the instrument is one of the
most useful of the modern purposes to which it has
been devoted. For without it we must resort to the
more formidable operation of version, or await the
slow, often fatally slow, spontaneous dilatation of
the cervix.
III. Certain accidents of labor require a more or
less prompt termination of the labor. In prolapse
of the funis, when it cannot be permanently replaced,
the forceps may be used in the interests of the child.
The forceps blade may be of great utility in itself, in
pushing the funis up and out of the way, after
which we may make as much or as little traction as
is called for, and either promote the delivery with
them or allow it to go on without further interfer-
ence. This will not interfere with the trial of the
genu-pectoral posture in replacement. This position
has been found useful as a preliminary measure in
the application of the forceps in these cases, and is
also recommended by Mossmann (Am. Journ. Obst.,
Jan. 1879), in certain cases of spinal and pelvic
deformity. There is such an entire reversal of direc-
tion in this position that the operator must know
well what he is undertaking ; otherwise it is calcu-
lated to be of service.
WHEN TO USE THE FORCEPS. 165
Convulsions, — The typical puerperal convulsion
comes on usually when the head has reached the in-
ferior strait and the bearing down efforts of the
mother give rise to cerebral congestion. The indica-
tion is then plain to apply the forceps at once and
deliver as speedily as possible, administering ether
in the meantime, if it is at hand. We thus eliminate
one of the causative factors of the eclampsia and gen-
erally put an end to the seizures. In the cases
which occur during the first stage, rapid delivery is
not so necessary. We have ample time to obtain the
influence of chloral by the mouth or rectum, bleed,
or otherwise control the convulsions according to our
lights. Dilatation is usually rapid, and when com-
plete we can apply the forceps with less risk. In
cases of hemorrhage before delivery the forceps also
afford us the means of promptly terminating the labor.
IV. When rupture of the uterus has taken place,
the j)revailing practice is to deliver ^6?^ vias natu-
rales, either by the forceps or version if possible.
The propriety of this begins to be questioned.
First, we will probably enlarge the rent already
made. Second, we leave the rent to close spon-
taneously, which seldom happens. Thirdly, we do
not take away what is quite as important should be
removed as the child, the blood and fluids which es-
cape at the time of rupture. The elaborate statistics
of Dr. Trask show a better percentage for gastrotomy
than for ordinary delivery and with the improved
166 HOW TO USE THE FORCEPS.
methods of operating now in vogue there is no rea-
son why a much larger percentage should not recover
if we should at once proceed to open the abdomen
after the accident. The child can be removed, the
rent united by suture, the abdominal cavity thor-
oughly cleansed from extraneous fluids, and the
woman will be no worse oflE than after the Cassarean
section instead of almost uniformly perishing, as
when the abdomen is left unopened. It is true that
gastrotomy may be performed after delivery per vias
naturales, but the latter is an unnecessary step, and
the former would be frequently refused by the
woman or her family if she had been already deliv-
ered. Prevention is better than cure, and the for-
ceps will be found much more useful as a preventive
of rupture. When the uterine contractions are very
forcible without having any appreciable effect upon
the head, we may justly fear the occurrence of rup-
ture of the uterus. The exact amount of contrac-
tion which justifies interference may be left to the
judgment of the practitioner at the time. The for-
ceps may also be used for purposes foreign to their
original design. They may be inserted into the in-
cision made in the Ca^sarean section or gastro-ely-
trotomy, in order to grasp the head. They may be
used to deliver detached fibroid tumors from the va-
gina, or to extract foreign bodies, such as globe pes-
saries. But for such purposes the mechanical tact of
the operator in each case is a sufficient guide.
WHEN TO USE THE FORCEPS. 167
A few words may be added as to the possibilities
for harm possessed by the forceps. So far as the
mother is concerned we may reiterate the statement
that there is nothing in the right use of the instru-
ment which can by any possibility injure her. The
animadversions of the earlier writers were due, in
part, to their wrongly attributing to the instrument
what is tlie result of delay in labor, and in part to
the unavoidable injuries caused by an instrument
without a pelvic curve, to say nothing of the heavy,
thick, leather-covered blades which formerly belong-
ed to the forceps. But with the modern instrument
we can do harm only by violence in introduction, a
WTong direction in traction, or by too great haste in
completing the delivery. The anterior lip of the
cervix has been ground off, the pubic bones have
been fractured, the vagina lacerated, by such im-
proper uses ; but none of these things will happen
when the forceps are used as herein directed and as
common-sense would dictate. And in the normal or
but slightly deformed pelvis, it is equally true that
the forceps need do no harm to the child, if applied
to the sides of the head and used intermittently and
judiciously. It must be admitted that even those
who are skilled in their use are occasionally mistaken
in the diagnosis of the position of the head, and
hence apply them over the brow and occiput, but
this should not be laid to the charge of the forceps.
So, also, when the head is at the inferior strait, but
1G8 HOW TO USE THE FORCEPS.
has not completed rotation^ the exact state of affairs
may be overlooked and the forceps applied obliquely
upon the head. In occipito-posterior positions, es-
pecially when flexion has not taken place, the ends of
the forceps may unavoidably compress important
structures, and in deformed pelves indentations of
the cranium may be caused by the jutting promontory.
We may have, then, as the result of the forceps,
bruising or laceration of the child's scalp, facial pa-
ralysis, asphyxia from compression of the medulla,
indentations of the cranium. All of these are avoid-
able by applying the forceps to the sides of the head,
except those due to compression of nerve trunks in
occipito-posterior positions. Against these we have
no safeguard, except the early securing of flexion so
as to bring the line of the blades parallel to the oc-
eipito-mental diameter, and, failing this, the utmost
care in compression and traction, which as already
pointed out, is proper for other reasons as well. Di-
rect indentations of the cranium are rarely if ever
caused by the direct pressure of the forceps, but the
amount of traction necessary to bring a head past a
jutting promontory may cause the latter to indent
the head, as happens also in head-last labors. The
etiology of idcntations in general is well worked up
by Dr. J. Trush, to whose paper* the reader is re-
ferred for a more extensive discussion.
* " Ameiicau Journal of Obstetrics," July, 1879.
THE END.
r:l^ii«Fr-r
THE INTERNATIONAL
MEDICAL
ANNUAL 1890.
A Complete Work of Reference for Medical Practitioners.
Edited by P. W. WILLIAMS, M.D., Secretary of Staff.
As.sisted by a Corps of Toirty-Seven Distinguished Collaborators wide-
ly known in Europe and America.
First. The Dictionary of New Remedies,
With this is incorporated a review of the general Therapeutics of the
year and to which is added an Index of Diseases showing at a glance
the new remedies which have been recommended in any given disease,
and the page upon which the prescription will be found. It forms a
very comprehensive and useful survey of the multitude of new remedies
that have been recently brought under the notice of the medical pro-
fession in Europe and America. The fact that it includes the results of
recent experiments with many valuable drugs that have lost the charm
of novelty makes the volume more complete as a reference book; ar-
ranged in dictionary order under the name of the remedy.
Second. The Dictionary of New Treatment,
Comprises a remarkably full resume of the medical literature of
the year giving the new methods of treatment in Medicine and Surgery
which have come to light in all parts of the world and been recom-
mended since :jhe publication of the Dictionary of New Treatment of
1889 ; with original articles, suggestions, and observations by specialists
and the editors in charge of the several departments. A veritable mul-
tum in parvo of information of great value for the dispensing chemist
as well as the medical practitioner. Alphabetically arranged under the
name of the disease; each article bearing the name of the contributor.
8th Annual Issue.] [Uniform with "Medical Classics Series."
In one large octavo Volume. Illustrated. Over 600 pages. $2.75.
E.B. TREAT, Publisher, 5 Cooper Union, NewYorl<.
Medical Students and Agents Wanted.
DISEASES
OF THE
HEART AND LUNGS,
By JAMES R. LEAMING, M.D.,
Emeritus Professor of Diseases of the Chest and Physical Diognosis in
the New York Polyclinic ; and President of the Faculty,
Special Consulting Physician in Chest Diseases,
St. Luke's Plospital, New York, etc.
The author of this treatise has made the diseases of the
heart and lungs his special study for many years. His care-
ful investigations as a Practitioner and Professor in New
Vork, his observations in Public Hospitals and private con-
sultations were occasionally embodied in papers, read before
the Academy of Medicine or published in Medical Journals.
These having been discussed, the views presented being some-
times modified, strengthened or confirmed, were afterwards
tested and in their revision, are given to the profession in this
permanent form.
Dr. Leaming^s well-known acute faculty of discriminating
sounds and his attention to the minutest details in the diag-
nosis of a case gives great weight to his judgment. The use
and effects of certain medicines in the treatment of special
cases have also been watched with singular attention and the
effects are recorded with great particularity and with very
helpful observations. Nothing in fact has been omitted in the
consideration of the class of diseases pertaining to the heart
and lungs, that the most advanced investigations have ascer-
tained or the most skillful practioners have found remedial
or beneficial.
The book is therefore submitted to the profession as a
valual^le contribution to the fuller knowledge and treatment
of diseased or abnormal conditions of the cardiac and respi*
lory system.
In one large oct. foL, 300 pages. Price, $2,75.
K. B. TREAT, Publisher, 5 Cooper Union, New York.
EXCESSIVE
VENERY, MASTURBATION
AND
CONTINENCE.
THEIR ETIOLOGY, PATHOLOGY AND TREATMENT IN-
CLUDING DISEASES RESULTING
THEREFROM.
BV
JOSEPH W. HOWE, M.D.,
Late Professor of Clinical Surgery in Bellevue Hospital Medical College,
Fellow of the New York Academy of Medicine, Visiting Sur-
geon to Charity and St. Francis Hospitals.
Second Edition Revised.
This volume contains in addition to the results of the author's experi-
ence obtained in hospital and private practice, the substance of a course of
lectures delivered in the Medical Department of the University of New-
York, on the Results of Excessive Venery, Masturbation and Continence,
to which is added the peculiar methods of treatment employed by various
authorities in Europe and America. The causes, diagnosis and treatment
of the various disorders that marshal themselves under the general term
of excessive venery are clearly and instinctively presented, and many
curious experiences detailed bearing upon the mental influences connected
with the use and abuse of the sexual act. The volume is complete as a
book of reference for the student and practitioner of medicine.
This is a judiciously written book from the standpoint of a practical
surgeon of large experience. The author shows himself a master of the
subject in all its various details. — New Yoi'k I\Tedical Record.
Every topic in the book is carefully, judiciously, and legitimately
handled, and there is need of just such a treatise by every general practi-
tioner who has over and over again been disheartened by the treatment of
the stubborn affections considered in this excellent volume. — Phila. Medical
Bidleiiii.
The etiology, pathology, and diagnosis of the affection in question are
well stated, and the various methods of treatment are ably discussed. No
resources known to modern medicine or surgery being neglected. — Louisville
Medical News.
To say that the book is readable is putting it very mildly. That it is
interesting, all who read it will testify. * * * Continence is
treated from a religious, a moral, a physiological, and a pathological point
of view, and while the author's teachings are bold, they are judicious. — -
Phila. Medical World.
There are few volumes that will so well repay the reader who has not
given attention to the class of diseases with which it deals. — Cincinnati
Lancet and Clinic.
The work is concise and practical, and yet sufficiently full to make it
a valuable work of reference. The chapters on treatment are especially
complete. — Baltimore Medical Chronicle.
In one large Octavo Volume. 300 pages. Handsomely Bound, $2.75.
E. B. TREAT, Publisher, 5 Cooper Union, New York,
HANDBOOK OFjREATMENT.
ARRANGED AS AN ALPHABETICAL INDEX OF DISEASES, TO FA
CILITATE REFERENCE, AND CONTAINING NEARLY
ONE THOUSAND FORIVIUL>E.
By William Aitken, M.D., (Edinburgh,) F. R. S.,
Professor of Pathology in the Army Medical School; Examiner in Medicine for the Mili-
tary Medical Services of the Queen; Fellow of the Sanitary Insntute of Great
Britian; Corresponding Member of the Royal Imperial Society
of Physicians of Vienna; and of the Society of Medi-
cine and Natural History of Dresden, etc.
Edited with Notes and Additions
By a. D. ROCKWELL, A.M., M.D.,
Late Electro Therapeutist to the New York State Woman's Hospital.
There is, perhaps, no more striking characteristic of the medical prac-
titioner of to-day, and none better illustrating the pervading spirit of the
age, than the universally observed tendency among medical men to shun (in
medical literature) the unrealities of theoretical discussion, and to appropri-
ate with avidity only facts which they can instantly transform into working
force.
A book which is at once concise and comprehensive, arranged so that
the practitioner, given a disease to treat, may have before him in a nutshell
the latest treatment recommended by the best authorities ; and a book
which is above all else a book <?/ TREATMENT, we here offer to the profession.
It is composed of the chapters on Treaitnettt compiled from the seventh
(latest) edition of Dr. Aitken's classical work on the Science and Practice
of Medicine, which chapters have been revised and rearranged, by Dr.
Aitken, so as to make them more available for reference. The work not
only embrace the experience of its distinguished author, but also that of
many widely known authorities.
The N. V. Medical Recora says : ' ' This book is a compilation from the
last edition of Dr. Aitken's well-known work on * The Science and I'ractice
of Medicine,' and comprises the cliapters on treatment as written by that
author. The diseases are arranged in al})liai)etical order, with numerous
cross references, whereby the reader is enabled to turn at once to any de-
sired su])ject without being oldiged to refer to an index. Under each
lieadi ng is found a short definition of the disease, and then follows imme-
diately the portion on treatment. Dr. Aitken's work is too well known to
require any discussion here.
The New E^igland Medical Monthly says : " From (beginning to end
it proves itself to ])e one ot those rare ])ooks which the general practitioner
should have and always wants on his desk. At a glance he finds in a nut-
shell many things which to work out from from his library would consume
too much valuable time.
The Medical Age says : " The characteristics of the book before us a^
its conciseness aiul its comprehensiveness. It aims to be thoroughly prac-
tical, and to this end devotes the smallest possible space to definitions of
the diseases which it discusses, and the largest possilile space to treatment.
Us foraiula will cfjinmend it to a large class of practitioners.
In one large octavo vol., 444 pages, handsomely bound. Price, $2.75.
E. B. TREAT, Piiblisiier, 5 Cooper Union, New York.
HAMII-TON'S
MEDICAL JOBISPMDEEE.
A MANUAL OF MEDICAL JURISPRUDENCE,
WITH SPECIAL REFERENCE TO
DISEASES AND INJURIES
OF THE NERVOUS
SYSTEM.
—BY—
ALLAN McLANE HAMILTON, M.D.,
One of the Consulting Physicians to the Insane Asylums of
New York City, etc.
Second Edition Revised*
This is a practical work, doing away with those long and tiresome details which works
on this subject so frequently give ; yet all necessary details are given — plain, clear, and
concise.
It is very fully illustrated with cases drawn largely from A tnerican sources, and hence
better calculated to meet the wants of Atnerican physicians and legal advisers— a feature
that is not always to be found in similar treatises. The leading chapters embrace Insanity
in its Medico-legal Relations ; Hysteroid Condition and Feigned Disease ; Epilepsy ;
Alcoholism ; Suicide ; Cranial Injuries and Spinal Injuries,
The first chapter defines Insanity, its general indications, classification and Hereditary
Influence — Including Post Mortem Examination of the Insane (with plates of the typical
and a typical brain. Under the legal Relations of Insanity we have Legal Tests— The
Guiteau case — Physical Tests — Duties of Medical Experts — Tricks of Counsel — Illusions,
Hallucinations and Delusions — Reasoning Mania — Contracts made by the Insane — Testa-
mentary Capacity — Old Age and Dementia— Undue Influence — Medico-Legal Relations of
Aphasia — Marriage and Insanity — Insurance Frauds — Responsibility of Deaf and Dumb —
Criminal Responsibility — Responsibility in Relation to Imbecility — English Test of Re-
sponsibility ; American Decisions on it — The Test of Right and Wrong— Impulsive
Insanity — Commitment of Lunatics and State Laws Regulating it — Concealed and Feigned
Insanity, etc. The chapters on Cranial and Spinal Injuries are particularly valuable, for
the numerous decisions cited from our courts in connection with suits for damages from
Railroad Collisions, etc.
"An Examination of this work demonstrates its worth. In these days of malingering
the slightest injury form a fall is too often held to have caused injury to the spine, a mul-
xitude of symptoms being referred to concussion. Works upon ' Concussion of the Spine'
have given an impetus to this imposition, and the needy member of the bar has often
utilized it to hll his coffers through the mulcting of corporations for this put up condition.
We do not mean '^^y Skj , nor does Dr, Hamilton, that concussion of the spine never does
take place, but the instances of its occurrence are very rare. Every physician and surgeon
should have a copy."— The Therapeutic Gazette,
"There is a good deal of value in it and a largenumber of illustrative cases are given,
both old and recent, which have never before been collected in book form, though mostly
familiar to the alienist, and will prove of particular value to *he lawyer who wishes to
crowd the interstices of his elastic brain with numerous facts for the morrow's fray, in
which he will give the spectator the impression that for years he has made a special study
of insanity.— The Boston Medical and Surgical Journal
\' The lawyer who wants something to the point in a pending case, and the physician
who is on the eve of running the gauntlet of the court as an expert witness upon some
vexed questions of mental deflections, will find a treasure in this work." — The Louisville
Medical News. \ , -
One large Octavo Vol. 380 pages. Illustrated. Handsomely Bound, $2.75
E. B. TREAT, Publisher, 5 Cooper Union, New York.
The Pathology, Diagnosis and Treatment
OF THE
DISEASESOF WOMEN,
BY
GRAILY HEWITT, M,D.. London, F.R.C.P,,
Professor of Midwifery and Diseases of Women, University Co'lego. and
Obstetric Physician to the Hospital ; For.nerly Presida-nt of the
Obstetrical Society of London ; Honorary Fellow of the
Obstetrical Society of Berlin ; Honorary Fellow of
the Gynaecological Society of Boston.
A New American from the Fourth Revised and Enlarged
Londo7i Edition,
Edited, with Notes, Additions and Illust rations.
BY
H. MARION-SIMS, M.D.,
Attending Surgeon to St. Elizabetli's Hospital, N. Y., Etc.
Three Octavo Volumes, Over i,ooo Pages, With 240
Illustrations.
It may seem superfluous to say a word in commendation of Dr.
Graily Hewitt's great work — a work which has ])een accepted as the
standard by the i)rofession Ijoth in Kni^land and America, and whicli lias
heen adopted as a text book in twenty or more medical colleges.
The author, in tlie preface, says: — **Ten years have elai:)sed
since the last edition of this wtjrk was published. What I have gained
from observation and experience during these ten years has been here faith-
fully and truly set down. * * * The greater part of this new edition
has been rewritten."
Dr. Sims has given the work a thorough revision, freely criticising,
and commenting on the authors's views, and making many valuable addi-
tions in the text and illustrations.
In three large octavo volumes, handsomely bound.
Vol. I. contains 350 pages and 104 Illustrations, Price, $2 75
" II. " 3" ' " 64 " 2 75
" HI. " 365 " 72 " 2 75
E. B. TREAT, Publisher, 5 Cooper Union, New York.
A PRACTICAL'TREATISE
Mm 01
ON THE
m
If
iiiL
D
Lil
BY
GEORGE THOMAS JACKSON, M.D.
Instructor in Dermatology in the New York Polyclinic ; Assistant
Visiting Physician to the New York Skin and Cancer
Hospital ; Member of the New York
Dermatologrcal Society ; etc.
This work discusses the various phases pertaining to the care of the
Scalp and Hair, and to the treatment of its diseases. The parasitic, as
well as the no^-parasitic diseases, which affect it, and those of the Scalp
iH which the Hair is implicated are all carefully explained. The hygiene
of the hair, even to minute points, is fully described and directions
given for its care in every particular. The best plans of treatment by
the most eminent men of this country and Europe for the various dis-
eases of the Hair and Scalp are also fully set forth.
AVith the object in view of rendering this volume of still greater
practical value, its contents are illustrated by numerous and specially
selected wood-cuts which demonstrate to the eye what the text places
before the understanding.
The Dermatological qjecialist will also find in this volume a most
carefully arranged and voluminous bibliography collected from over
six hundred journal articles, besides special and general treatises.
To the general medical practitioner who finds it so difficult to
learn what is the proper thing to do for a *' hair case," this book will
prove invaluable, as he will find scattered through it many prescriptions
that cannot fail of being useful to him. The author has made the mat-
ters of diagnosis and treatment specially prominent, carefully pointing
out the differences between the various diseases of the hair, the
rpecial and appropriate remedy needed for each, and the best means for
their prevention.
In One Octavo Volume, 356 pages. Illustrated by
special drawings and photographs from life. Price, $2.75-
E. B. TREAT, Publisher, 5 Cooper Union, New York.
INSANITY.
Its Classification, Diagnosis and Treatment;
A Manual for Students and Practitioners of Medicine.
BY
E. C. SPITZKA, M. D.,
Professor of Medical JvirispruJence and of the Anatomy and Physiology of the
Nervous System, at the New York Post-Graduate School of Medi-
cine, President of the New York Neurological Society, etc.
In this, the first systematic treatise on Insanity published in America since
the days of the immortal Rush, the author has made its definitions, classifica-
tions, diagnosis and treatment plain and practical ; and has laid particular
stress upon points comparatively new and has succeeded in presenting the sub-
ject in such a manner that the rudiments of this difhcult and intricate branch
of medicine may be easily acquired and understood.
E^^This important work has already been adopted as the Standard Text-
Book in tlie College of Physicians and Surgeons of New York, the College of
Physicians and Surgeons of Baltimore, the Rush Medical College of Chicago,
the College of Physicians and Surgeon? of St. Louis, and the Medical-Chirurgi-
cal College of Philadelphia.
1 he Boston Medical and Surgi-
cal Journal says: *' Conservative and
in accordance with the highest principle
of scientific invest igation, which accepts
no half-truth, but proven facts alone.
Its chief merit consists in its
effort to present the subject in a clear,
accurate, and scientific manner."
The Louisville Medical News
says: " The book is written in a clear
and forcible style, and while the practi-
cal side of the question is kept constant-
ly in the foreground, it abounds in inci-
dents, historical and modern, whicli
admirably illustrate the points made by
the author, and contribute largely to the
entertainment of the reader."
The Weekly Medical Review
tays: "It cannot be neglected by any
one desiring a clear and comprehensive
review of the whole stibject of insanity."
The New York Medical Record
says: *' The accomplished author dis-
plays throughout a masterly grasp of his
intricate subject, and a familiarity with
its bibliography which is in the highest
degree commendable. . . The pre-
sentation of his arguments is direct ana
decided, his illustrations usually apt and
well put, and his expositions of the
most important points forcible."
The Cincinnati Lancet and Clinic
says: "A great variety of useful infor-
mation and an intelligent discussion."
The American Medical Weekly
savs: ** It is clear, it is up to the times,
and last but not least, it is practical."
The New England Medical
Monthly says- " IJy far the best book
that has appeared in English in this
department of Science.'*
In One Large Octavo Volume, 424 pages. Illustrated. $2.75.
E. B. TREAT, Publisher, 5 Cooper Union, New York.
DISEASES OF THE HEART,
By ALONZO CLARK, M.D., LL.D.
Emeritus Professor of the Principles and Practice of Medicine, etc
College of Physicians and Surgeons, New York.
This book is the crowning effort of its distinguished author.
Few, if any, in the medical profession have attained to higher
eminence as a skillful diagnostician. Filling for many years the
chair of Professor of the Principles and Practice of Medicine in
the College of Physicians and Surgeons, New York ; and standing
in the front rank, if not the first oi ^'Consulting Physicians" in
liis specialty, he enjoyed unsurpassed opportunities from personal
observation, original investigation and familiarity with the literature
of the subject, of becoming the ablest expert of his time.
The information gathered in this volume embodies the sub-
stance of his teachings and lectures on '' Diseases of the Heart **
given to his students. Nothing is omitted which would tend to
give a clear exposition of the views which he inculcated as teacher.
The volume cannot therefore fail of being of great value to
practioners, as it contains the results of a singularly calm and
judicious mind of one who had long and ])re-eminent experience,
and wliose ripened harvest of thought is gathered into this sheaf,
which ought to find an honored place in the medical granary
among other distinguished sheaves.
It gives emphasis and increased interest to this book to know
that it is the orly portion of Dr. Clark's many and valuable articles,
lectures, teachings, and medical examinations given to the Pro-
fession in permanent published form.
One Octavo Volume, 251 pages. Price, $2.75.
E. B. TREAT, Publisher, 5 Cooper Union, New York.
SEOWK'S MEDICAL BIAaHOSIS.
A MANUAL OF CLINICAL METHODS By J Graham Brown
M.D., Fellow of the Royal College of Physicians of Edinburgh,
Late Senior President of the Royal Medical So-
ciety of Edinburgh.
SECOND EDITION ILLUSTRATED.
This work is the embodiment of the thorough and conscientious labors of
Dr. Brown of Edinburgh, who has won a just celebrity in his
department of medicine- Its contents are
summarized as follows:
Chapter I. The General Aspect,
Condition and Circumstances of
a Patient. Preliminary Inquiries.
II. Alimentary System.
Objective — Subjective — Excretory
Phenomena,
III. Examination of the
Abdomen.
Its palpitation and Percussion.
IV. Hi^MoPoiETic System.
Lymphatic Vessels and Glands — Ex-
amination of the Blood.
V. Circulatory System.
Subjective Phenomena. — Palpation.
— Percussion. — Auscultaton of the
Heart. — Examination of the Arte-
ries, Capillaries, and Veins.
VI. Respiratory System.
Subjective Phenomena. — Examina-
tion of Nares and Larynx. Pal-
pation.— Percussion of the Chest.
— Auscultation . — Respiration.
VII. Integumentary System.
Subjective and Objective Symptoms
— Eruptions.
VIII. Urinary System.
Subjective Symptoms. — Normal con-
stitutents of Urine. — Abnormal
Constitutents of Urine. — Urinary
Sediments.
IX. Reproductive System.
The Female Reproductive Organs
and Functions — Physical Exami-
nation,
X. Nervous Sysi^em.
Sensory — Motor — Trophic- Cerebral
and Mental Functions. — Condi-
tion of Cranium and Spine.
XI. Locomotor Y System,
Bones — Joints — Muscles.
PRESS NOTICES.
'• A clearness and completeness which is not to be found in any boolf
of the kind with which we are a.cquR[n{ed."—Bntis/i Medical Jouriiai,
* • The author of this manual deserves the thanks of all clinical students
(and we may add, of teachers also) for the excellent work he has pro-
duced."— The Lancet.
"On voit que cet ouvrage, qui J'ailleurs est tres au courant de la
science, n'est pas une simple compilation, mais qu'il renferme des parties
vraiment origin ales." — Paiis Revue de Medicine,
"His plan is not that found in many other works on Diagnosis — that
of taking up leading symptoms and tracing them in various diseases. He
pursues what we may call the anatomical method, thus passing in review
the whole body. This is a natural and easy plan of arranging his material,
and is quite as advantageous as any other." — Phila, Medical and Surgical
Reporter,
One Large 8vo Vol., 285 Pages, Handsomely Bound, $2.75.
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Favorite Prescriptions
OF
DISTINGDISHED PRACTITIONERS
WITH
ITOTES OH THEATMEHT.
Compiled from the Published Writings or Unpublished Records of Drs.
Fordyce Barker, Roberts Bartholow, Samuel D. Gross, Austin Flint,
Alonzo Clark, Alfred L. Loomis, F. J. Bumstea 1. T. G. Thomas,
H. C. Wood. Wm. Goodell, A. Jacobi. J. M. Fothergill, N.
S. Davis, J. Marion-Sims, Wm. II. By ford, L. A. Duh-
ring, E. O. Janevvay, J. M. Da Costa, J. Solis Cohen,
Meredith Clymer, J. Lewis Smitli, W. H. Thom-
son, C. E. Brovvn-Sequard, M. A. Pallen,
Geo. H. Fox, W. A. Hammond,
E. C. Spitzka, etc., etc,
BY
B. W. PALMER, A.M., M.D.
JVeWy Enlarged and Revised Edition^ with Blank Pages inter-
leaved i?i its Several Departments for Registe7'tng
Formulce worth Preserving.
^' We believe that the physician will find that th^s guide
will very materially lighten his labor in searching lor the
most reliable agents in treatment, indeed will be an aid to him
which he cannot well dispense with after once possessing it.'*
— Medical Gazette.
'"' The modest volume in hand contains a large number
of good prescriptions. It is gotten up in dainty style, and
the publisher has done his work well." — St. Louis Clin. Rec.
In one large Octavo volume. 256 pages. Handsomely bound, $2.75
E. B. TREAT, Publisher, 5 Cooper Union, New York,
NERVOUS EXHAUSTION
[Neurasthenia] ,
Its Hygiene, Causes, Symptoms and Treatment,
By GEORGE M. BEARD, A.M., M.D.,
Formerly Lecturer on Nervous Diseases in the University of the City of New
York ; Fellow of the New York Academy of Medicine, etc.
Second Edition Revised and Enlarged by A. D. ROCKWELL, A,IVI., M.D.,
Professor of Electro-Therapeutics in the New York Post-Graduate Medical
School and Hospital, P'ellow of the New York Academy of Medicine, etc.
Neurasthenia. — In spite of its frequency and importance, although long
recognized in a vague way among tne people and the profession under such
terms as "general debility," "nervous prostration," *' nervous debility,"
"nervous asthenia," " spinal weakness," it is beginning to find recognition
in the literature of nervous diseases. It is the most frequent, most interest-
ing, and most neglected nervous disease of modern times.
Among specialists and general practitioners alike, there has been, on the
whole subject, a fearful and wondrous confusion of ideas.
The present work is the result of the experience and study of my entire
professional life in the subject to which it relates. — (From Author's Preface.)
Neurasthenia is now almost a household word, and equally with the
term malaria, affords to the profession a convenient refuge when perplexed
at the recital of a multitude of symptoms seemingly without logical connection
or adequate cause.
The diagnosis of neurasthenia, moreover, is often as satisfactory to the
patient as it is easy to the physician, and by no means helps to reduce the
number who have been duly certified to as neurasthenic, and who ever after,
with an air too conscious to be concealed, allude to themselves as the victims
of nervous exhaustion. The doctrine to be taught and strongly enforced is
that many of these patients are not neurasthenic, and under any hardly con-
ceivable circumstance could they become neurasthenic. They do not belong
to the tyep out of which neurasthenia is born, either mentally or physically.
Many of them are unintellectual, phlegmatic, and intolerably indolent,
and are pleased at a diagnosis which touches the nerves rather than the
stomach, bowels and liver. Instead of rest, quiet and soothing draughts, they
need mental and physical activity, less rather than more food, depletion rather
than repletion. — Froi7i Editor s Preface.
In one large octavo vol., nearly 300 pages. Price, $2.75.
Uniform in style with Medical Classics, Price of the 1 2 Vols.,
E. B. TREAT, Publisher, 5 Cooper Union, New York.
A PRACTICAL TREATISE
ON
HEADACHE, UEURALaiA,
Sleep and its Derangements,
AND SPINAL IRRITATION.
By J. LEONARD CORNING, M.A., M.D.,
Consultant in Nervous Diseases to St. Francis Hospital; P'ellow of the New
York Academy of Medicine; Member of the New York
Neurological Society; &c.
AUTHOR OF
A Treatise on Hysteria and Epilepsy," "Local Anaesthesia," "Brain
Exhaustion, with some Preliminary Considerations on Cerebral Dy-
namics," "Carotid Compression,'^ "Brain Rtst, being
a Disquisition on tlie Curative Properties
of Prolonged Sleep,'' etc., etc.
In this volume the author has undertaken the difficult task
of explaining the nature and treatment of those pains about the
head, which constitute such a fruitful source of misery. Dr.
Corning is eminently qualified for the work, and has long been
known to the profession as a brilliant and indefatigable laborer
in the cause of practical neurology. His contributions to neuro-
therapeutics are among the most practical and suggestive
additions which have been recorded during recent years. To
rare powers of perception Dr. Corning unites, in an eminent
degree, the faculty of imparting knowledge in an entertaining
manner. His style is at once lucid and forcible, not the least
of his charms being the power to awaken thought as well as
to impart information.
In all matters involving the treatment of pain Dr. Corning
is an acknowledged authority, and the precepts which he
inculcates are alike worthy of the physiologist and the accom-
plished physician.
The present treatise on "Headache and Neuralgia" is
replete with suggestion and useful matter, and no thoughtful
physician can fail to derive both inspiration and practical
assistance from its perusal.
In one large oct. vol., nearly 300 pages. Price, $2.75.
Uniform in style with Medical Classics ; Price of the 1 2 Volumes,
E- B, TREAT, Publisher, 5 Cooper Union, New York.
BRIGHT^S DISEASE.
A SERIES OF POST GRADUATE LECTURES.
By ROBERT SAUNDBY, M.D., Edinburgh.
Fellow of the Royal College of Physicians, London ; Emeritus
Senior President of the Royal Medical Society ; Fellow
of the Royal Medical Chirurgical Society, etc., etc.
ITS CONTENTS : Pathological Skction I. Comprises : Album-
inuria— Pathology of Dropsy — of Polyuria — of UR/t:MiA — Cordio-
Vascular, and Retinal Changes. II. Clinical Examinations and
Tests of the Urine in Health and Disease. III. Bright's Disease,
ITS History — Classification — Etiology— Anatomy of 'jhe Kidney —
Febrile Lithemic and Obstructive Nephritis — Complications of
Chronic Cases — Treatment — Fifty Illustrations.
These Lectures are specially designed for Practitioners, and
are an expansion of a Post Graduate Course on '^ BrigJifs Disease,''
and coming from a thoroughly competent hand will be welcomed
by the medical profession. The author, by talent, position, study,
long experience and special attention to Renal diseases is amply
qualified to present such a volume. The whole subject has been
thoroughly investigated, the present state of contemporary knowl-
edge on this disease is clearly stated, and additions and suggestions
which have resulted from thirteen years Clinical and Pathological
study of Brii^ht's Disease under the most favorable environments
have been made. Fifty illustrations from microscopical prepara-
tions of Urinary and Renal diseases are given and inserted in
their appropriate places throughout the work. An alphabetical in-
dex closes this valuable addition to the Medical Classic Series.
In one large octavo vol., nearly 300 pages. Illustrated. Price, $2.75.
Uniform in style with Medical Classics; Price of the 16 Vols., %
E. B. TREAT, Publisher, 5 Cooper Union, New York.
/
HOW TO USE THE FORCEPS:
WITH AN INTRODUCTORY ACCOUNT OF THE
FEMALE PELVIS;
AND OF
THE MECHANISM OF LABOR.
BY
HENRY G. LANDIS, AM., M.D.,
Professor of Obstetrics and Diseases of Women and Children in Starling Medical
College, Columbus, O.
This handy volume is an eminently practical work and must prove
invaluable to the student, obstetrician, and physicians generally.
Twenty years ago it would not have been difficult to have found
many respectable physicians in full practice who had never used obstet-
rical forceps, and among that number some who considered the employ-
ment of forceps as meddlesome midwifery of the worst sort. To-day
the best masters of the art of obstetrics teach with great earnestness
their proper use, and our medical literature abounds with able articles
on the subject. In this work the subject is discussed from an entirely
new standpoint, and is endorsed by our best informed obstetricians. It
is issued in a handy volume, which is more convenient to consult, and
will be found much more full than the section on this subject in most of
the text-books.
It is an eminently practical work, the subject is fully presented in
every aspect ; a clear and forcible argument is made for the proper use of
the forceps. The practitioner and student will, in this well-written
treatise, obtain many valuable hints, more likely to be treasured and
retained than those scattered throughout the elaborate and diffuse
works on obstetrics.
The New York Medical Record says : ** Prof. Landis has given
Ufi a very practical, comprehensive and interesting work upon the
mechanism of labor and the use of the forceps. It can be read and
studied with profit by evciy general practitioner."
One i2mo Volume,' fully illustrated with 28 practical outlines.
In extra cloth binding. BMICE, $1.50.
E. B. TREAT, Publisher, 5 Cooper Union, New York.
PHOTOGRAPHIC ILLUSTRATIONS OF
SKIN DISEASES.
[Forty-eight auarto Plates, Sixty Cases from Life.]
By GEORGE HENRY FOX, A.M., M.D.,
Clinical Lecturer on Skin Diseases, College of Physicians and Surgeons, New York ?
Surgeon to the New York Dispensary, Department of Skin and Venereal Diseases ;
Fellow of the American Academy of Medicine ; Member of the New York
Dermatological Society, the American Dermatological Association, etc.
The large experience and reputation of Dr. Fox in this department
eminently qualify him for the preparation of so important a work.
As Surgeon to the Skin and Venereal Department of the New York
Dispensary, where upward of five thousand cases are treated annu-
ally, he has had ample amount of clinical material from which to
select cases. He has had access to and selected from several thou-
sand negatives, taken from patients in Bellevue and Charity Hos-
pitals, He has also drawn from other Dispensaries and Hospitals
both in New York and Brooklyn, through the kindness of physicians
in charge.
The COLORING is a special feature of the work, which has been
entrusted to a skillful anatomical artist, J. Gaertneu, M.D., for-
merly a physician and student under Hebi^a, in the General Hospital
of Vienna. These plates are carefully colored by hand and more ac-
curately represent disease than any lithographs or colored photo-
graphs which have ever been offered to the profession.
./
CONDITIONS. — The work is published in Twelve Parts, each part consisting cf
four plates printed from the original phot()grai)hic negatives, by a new and indexible
process, on lino quality of heavy card-board, 10 x 12 inches, colored by hand, giving
in each case the characteristic and life-like effects of the disease. Tv;o pages of
text accompany each plate.
This work will be sold only by our duly authorized Canvassing Agente.
No Subscriber's name will be taken for less than the entire work.
price:, per part, S2.
Complete, Half Koan Bindiuj,', $26.75; in Half Turkey Morocco, $28.
»♦«
NOW READY. FHOTOQBAFHIC ILLUSTEATIOITS OF
Cutaneous syphilis
By GEORGE HENBY FOX, A.M., M.D.
48 PlatcH, Seventy Cases from LifV. Terms and conditious as above.
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